Christy Sorden Patient Registration Form

(Please call to make an appointment 719-351-3155)

Which Number is Okay to Leave a Message *

Responsible Party Information

Spouse/Other Parent Information

Primary Insurance Information

Secondary Insurance Information

**Payment is expected at the time of service unless other arrangements have been made.  Any balance not paid by the end of the month is subject to a $15 fee.  As a courtesy of this office, your insurance will be billed, in which case you will be responsible for your deductible and co-payment at time of service.  It is your responsibility to contact your insurance company to find out what your plan limitations are.  In the event that it becomes necessary to assign this account for collection of your past due account, I agree to be responsible for all costs of collection including a 30% of your outstanding balance fee and all legal fees entailed in that process.
Click 'I Understand' Below *

Authorization

The above information is warranted to be true.  I agree to be responsible for the charges incurred.  If insurance is available, I authorize release of information for the purpose of filing claims, and also authorize payment of benefits directly to Christy Sorden, MA, LPC, NCC.
Click 'I Agree' Below *
SMS Text Message Appointment Reminders. *
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