Dr. Jagdish K. Soni Psychological Services, PC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Please provide your full address. If you are using Insurance, list the address listed with your Healthcare Insurance Provider

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Administrative

Referral source - Where did you hear about or read about Dr. Soni?

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Total Number of Insurance Plans

Please select the option that applies to you:

Insurance card upload

Upload a photo of your insurance card

Important: Coordination of Benefits (COB)

To avoid claim denials, insurance companies and the law require you to "Coordinate Benefits" (COB).This means you must call each of your insurance providers to let them know about your other coverages. Keeping this updated is part of your policy agreement; failure to do so can be flagged as insurance fraud and may result in your claims being rejected.

I acknowledge that I have read and understand my responsibility to complete a Coordination of Benefits for all active insurance policies."

Additional Insurance Coverage

If you have more than one plan, please provide the following details in the box below for each plan that is NOT your Primary Plan: (1) Additional Insurance Carrier & Policy Number, (2) Name of Policy Holder, and (3) Relationship to Patient (such as through a parent, spouse, or partner). If this does not apply, please enter N/A.

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Client Preferences

Please provide your availability for ALL SEVEN days (Mon thru Sun) of the week by listing all times for each day.

Please provide me with Your Availability with Time Zone. Though I do not typically work on weekends, sometimes it might be needed, please LIST all available times for each day of the week (DO THIS 8am, 9am, 10am, 11am, etc. NOT 8am to 5pm).

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Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.