Billing Information and Agreement
Billing Information and Agreement
Insurance Information
Patient Name: *

First Name Last Name
Date of Birth *

Month Day Year
Social Security Number: *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Place of Employment *
Work Phone Number *

Area Code Phone Number
Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Name *
Primary Insurance *
*PLEASE NOTE*

If you do not have Medicaid, you must contact Mosaic Psychological Services at (229) 233-8009 to process your credit card information. Services will not be rendered until valid credit card information is on file with Mosaic Psychological Services.
Insurance ID # *
Group # *
Cardholders Name *

First Name Last Name
Date of Birth *

Month Day Year
Cardholder's Social Security Number *
Do you have a Secondary Insurance? *

Yes No
Secondary Insurance
Contact Name
Insurance ID #
Group #
Cardholders Name

First Name Last Name
Date of Birth

Month Day Year
Cardholder's Social Security Number
Email Address (Must be a valid/active email address) *
Do you have Medicaid? *

Yes No
*PLEASE NOTE*

If you do not have Medicaid, you must contact Mosaic Psychological Services at (229) 233-8009 to process your credit card information. Services will not be rendered until valid credit card information is on file with Mosaic Psychological Services.
Failure to pay outstanding balances will lead to Collections, which will increase the amount owed.

Please be advised that there will be a $35.00 Service Charge for all returned checks. A 24-hour notice of cancellation is required for all appointments. Failure to provide a 24-hour cancellation notice will result in a charge for the full payment amount for your missed appointment. We will be unable to reschedule you for another appointment until the "no show fee" has been paid in full.

Your signature authorizes Mosaic Psychological Services to charge your credit care for any outstanding balances not covered by insurance. Please notify us if there are any changes to your existing coverage, failure to notify may result in you being responsible for the full amount.
I understand that a typed version of my name may be accepted as my original signature pursuant to the Georgia Uniform Electronic Transactions Act (O.C.G.A. 10-12-7). To accept the above statement, type "I Understand" in the box below. *
Signature (Please type) *
Date *

Month Day Year
Signature *

In order for the submission to be accepted, you must use the mouse and draw your name in the box above. Clear
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Billing Information and Agreement