Nancy Pentz

Individual & Couples Therapy

1875 I (Eye) Street, NW, Suite 500
Washington, DC  20006
202-441-0091
info@nancypentz.com

Forms

For your convenience, below are the forms I use to open your record, get information from your insurance company, and file insurance claims.

Intake Form (for new clients): You may choose to fill out the intake form in the office or print the form and fill it out and bring it with you to the first appointment.

Therapy Contract (for new clients): This is an agreement between you and me which outlines your rights and responsibilities and mine.

Insurance Claim Form HCFA 1500: This is a universal claim form used by all the insurance companies. There may be a shorter form that your employer provides that does not require as much detailed information; please bring your employer’s form with you if you prefer to use it rather than the universal form.