Emmaus Institute

Counseling Services
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154 Broad Street Nashua, NH 03063 (603) 886-3760 Fax (603) 821-6142
INFORMATION FOR PATIENT BILLINGS
Name: ____________________________________________ Date of Birth: ______________
Phone Number: Home ________________ Work _______________ Cell _______________
Address: _____________________________________________________________________
Insureds Name: ____________________________________ Date of Birth: ______________
Social Security Number or Certificate Number: _______________________________________
Group or Policy Number: ________________________________________________________
Insurance Company: ____________________________________________________________
Address of Insurance Company: ___________________________________________________

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Employers Name: _____________________________________________________________
Other Health Insurance? Yes ________ No ________
If yes, name of Insurer with Address: _______________________________________________
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For Office Use Only

Patient Account Number: ___________________________ Procedure Code: ______________
Therapist Name: __________________________________ Diagnostic Code: _____________

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