Sean F. Kelly, Ph.D.
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Sean F. Kelly, Ph.D.

Board Certified Clinical Psychologist




Personal information


Name:                                                                                                                    Date of Birth


If you are a student, permanent address:

e-mail                                                                                                                    Social Security #

Telephone number(s):


Insurance information:   (Please bring your insurance card to be copied)

Insurance Company

Claims mailing address

Name of subscriber:                                                                                          

(If not you, what is your relationship to subscriber?)                      (Subscriber's date of birth)

Insurance ID#

Group #

Did you obtain insurance authorization for this visit?


Whom may I thank for referring you to me?

I authorize Sean F. Kelly, Ph.D. to furnish my insurance carrier with all information to process my claim for services rendered. I understand that if my insurance should deny payment, I am responsible for the full charges.   If my plan requires preauthorization or referrals, I understand that it is my responsibility to request referrals from my primary care provider in advance and to be aware of the terms of my plan benefits. I agree to be personally and fully responsible for all charges. .I also acknowledge receipt of the required HIPPA notices and statements of patient rights and responsibilities which are available on the web site and in the office.  I can request a personal hard copy at any time.

Further, I am aware that appointments represent a commitment of time to me by the provider and that insurance will not cover missed appointments.  I must provide 24 hours' notice of cancellation.  If I give less than 24 hours' notice I will be responsible for a charge of $100.00.  If I miss an appointment without notice, I will be charged $125.00.

 I have read and agree to the above information:


_____________________________________________        ___________________________________________     ______________

Signed                                                                                       Print Name                                                                         Date

Sean F. Kelly, Ph.D.

Authorization to Release Confidential Information


You may find communication between your psychologist and your primary care physician (PCP), other health care provider, or other professional to be important in order to ensure comprehensive, coordinated quality health care. This form will allow me to share protected health information (PHI) with him or her.  This information will not be shared without your signed authorization and doing so is completely voluntary.  This PHI may include diagnosis, treatment plan and progress.

I, _____________________________________, d.o.b.___________________ authorize Sean F. Kelly, Ph.D., to release protected health information related to my evaluation and treatment to:





Your Rights

You can end this authorization at any time by contacting me.

If you make a request to end this authorization, it will not include information that has been used or disclosed based on your previous permission.

You cannot be required to sign this form as a condition of treatment, payment, enrollment, or eligibility for benefits.

Information that is disclosed as a result of this authorization form may be re-disclosed by the recipient and no longer protected by law.

You do not have to agree to this request to use or disclose your information.


I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it and that in any case this consent shall expire six (6) months from the date of signature, unless another date is specified.  I have read and understand the above information and give my authorization to release any applicable information to the above named individual or institution.

Signed:________________________________________  date______________

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