Murray Center for Behavioral Wellness 29500 Southfield Rd. Suite 100 Southfield, Michigan 48076 Ph: 248.962.3040 Fax: 248.504.5642 [email protected]murraycenter.com Date: ___________________ Patient’s Name: ________________________________________________________________ Address: ______________________________________________________________________ ______________________________________________________________________________ Phone (home): __________________ (work): __________________ (cell): _________________ Date of Birth: ___________________ Gender: ___Male ___Female Age: _____ Guardian (for children and adults when applicable): _________________________________ Marital Status (check one): Race (optional): ___ Never married ___ Divorced ___White ___Native American ___ Married ___Separated ___African-American ___Asian ___ Widowed ___Cohabiting ___Hispanic ___Other Family Members: Name/Age/Gender/Relationship ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Employer: _________________________ Occupation: ______________________________ School (for children, and adults when applicable): _________________________________ Grade: ___________________ Referral Source: _____________________________________________________________ Pediatrician/physician: ________________________________________________________ Emergency Information: Name of Emergency Contact: ____________________________Phone: _________________ Relationship to Patient: _______________________________________________ Insurance Information (Blue Cross Blue Shield Members only): Name of Insured/Subscriber: _______________________________ DOB of Subscriber: _____________ Policy ID#__________________________ Policy Group#_______________________
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Murray Center for Behavioral Wellness 29500 Southfield Rd ... · Murray Center for Behavioral Wellness 29500 Southfield Rd. Suite 100 Southfield, Michigan 48076 Ph: 248.962.3040 Fax:
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Murray Center for Behavioral Wellness 29500 Southfield Rd. Suite 100 Southfield, Michigan 48076
On______________________ (insert today's date) I authorize Sarah Murray, Ph.D. to initiate a recurring charge to the credit card indicated above for any outstanding charges after each visit (for any visit not paid the day of service). I understand I will only be charged for completed appointments and any late cancellation fees when an appointment is cancelled with less than 24 hours’ notice (or 48 hours for testing appointments).
I understand that I may cancel my recurring charge upon written notice to Sarah Murray, Ph.D. by writing to 29516 Southfield Rd Suite 100 Southfield, MI 48076.
If you have any questions about this transaction or if the credit card indicated above is lost or stolen, I agree to notify Sarah Murray, Ph.D. at once by calling at 248-962-3040 or by contacting her by mail or email.