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
www.drdavidbmiller.com

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

Referred by:
Date
MM slash DD slash YYYY
Personal Information
Name
First Last
Date of birth
Month
Day
Year
Social Security Number
Age
Marital Status
Contact Information
Home Address
Home Address Address Line 2 City State ZIP Code
Spouses Name
First Last
Home Phone
Cell Phone
Work Phone
Medical History
Family Physician
First Last
Present Medications
Emergency Contact
Name
First Last
Relationship
Phone
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.
Name
I, (YOUR NAME) understand that I am Financially responsible for all fees for services rendered.
First Last
Name
If applicable, I authorize treatment for my minor Child, (YOUR CHILD'S NAME).
First Last
Signature
Date
Month
Day
Year
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.
Signature
Date
Month
Day
Year
Please Initial
I have read the Florida Notice Form (HIPPA) and understand my rights.

New Patient Financial Form

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

Personal Information

Contact Information

Medical History

Emergency Contact