New Patient Financial Form

David B. Miller, Psy.D., P.A.

Diplomate, American Board of Professional Pyschology
Board Certified, American Board and Academy of Psychoanalysis
Practice of Clinical NeuroPsychology and Contemporary Psychoanalysis
Licensed Psychologist FL & CA
Boca Regional Hospital Physician #2076
5295 Town Center Road, Suite 401
Boca Raton, FL 33486
(561) 362-3739

As A Patient of Dr. Miller’S, a specific appointment time will be assigned to you. You will be finically responsible for that block of time. We do not accept credit/debit cards
  • MM slash DD slash YYYY
  • Personal Information

  • Contact Information

  • Medical History

  • Emergency Contact

  • As a patient of Dr. Miller's, specifically mutually agreed upon appointment time (s) will be reserved for you weekly. You will be financially responsible for that block of time and will receive a statement at the end of the month.
  • We Do Not accept credit/debit cards. Check or Zelle is acceptable.
  • Dr Miller is NOT A Participating Provider With Any Insurance Companies.
  • I, (YOUR NAME) understand that I am Financially responsible for all fees for services rendered.
  • If applicable, I authorize treatment for my minor Child, (YOUR CHILD'S NAME).
  • I agree and understand that it is the policy of Dr. Miller's office to turn over all unpaid balances to a collection agency or attorney after a period of 60 days. I agree to pay any collection costs and/or attorney's fees if my delinquent balance is placed with an agency of attorney for collection or suit. By Signing this financial consent, you are acknowledging that you have read, understood and agreed to its terms and are authorizing the office to release all necessary information to secure payment.
  • I have read the Florida Notice Form (HIPPA) and understand my rights.

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