Agency Registration Form
Please complete this form once a year. You may skip this form if you have recently completed it via docusign or paper for another Quest Center provider.
Basic Information:
Note: While Quest recognizes a spectrum of gender/sex, many insurance companies and legal entities unfortunately do not. Please be aware that the name and sex on record with your insurance company must be used on documents pertaining to insurance and billing. However, please also let us know the gender, name, and pronouns that you would like us to use.
Legal Last Name
Legal Full Name
*
MI
Preferred Name
Optional
Date of Birth
/
Month
/
Day
Year
Address
Street Address
Unit/Apt #
City
State
Zip Code
County
Housing Status:
Permanent
Temporary
Houseless
Other
Gender Identity:
Female
Genderqueer/Non-Binary
Male
Other
Legal Gender:
Female
Male
Gender Neutral
Intersex
Pronoun:
She
He
They
Other
Are you a new or returning client?
Please Select
New Quest Client
Returning Client
How did you hear about us?
Quest Client/Provider
Other Healthcare Provider
Social Service Provider
Insurance Company
Ad/Brochure
Quest Website
Social Media/Facebook
Other
Name or agency of referral source:
Contact Information:
Phone Number
Messages OK?
Cell
Yes
No
Work
Yes
No
Mobile
Yes
No
Email
example@example.com
Appointment reminders:
Phone
Text
Email
None
Would you like to receive Quest's Electronic Newsletter?
Please Select
Yes
No
Would you like to receive Quest's Electronic Newsletter?
Yes, subscribe me to this newsletter.
Billing Information
Insurance:
Medicaid/OHP
Medicare
VA
IHS
Self-Pay
Uninsured
Private
Other
Primary Insurance Carrier
Insurance ID Number
Secondary Insurance Carrier, if applicable
Are you the policy holder?
Please Select
Yes
No
Policy holder is the person that can name beneficiaries and coverage of a spouse, significant other, or other legal dependents.
Policy Holder’s Name
Policy Holder’s Date of Birth
Policy Holder’s Relationship to you
Please upload a picture of your insurance card. If you cannot upload a picture of your insurance card, please bring it to your first in-person appointment.
Browse Files
Drag and drop files here
Choose a file
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of
Are you seeking care related to a recent motor vehicle accident?
Please Select
Yes
No
Date of Accident
-
Month
-
Day
Year
Claim Number
Name of Claim's Adjuster
Phone
Attorney’s Name (If Applicable)
Attorney’s Address
Phone
Demographics:
Your optional responses help Quest develop culturally responsive and inclusive programs. As a Non-Profit, we collect this data in order to secure funding for marginalized populations, but understand that one’s identity can’t be reduced to a series of boxes.
Do you think of yourself as:
Lesbian/Gay
Straight/Hetero
Bi/Pan-sexual
Queer
Asexual
Other
Relationship Status:
Single
Partnered
Married
Poly
Seperated
Divorced
Widowed
Other
Please choose all options that best describe your racial or ethnic heritage:
Black/African American
White/European
Middle Eastern/North African
Asian
Native/Indian/Indigenous American
Alaska Native/Eskimo
Widowed
Native Hawaiian/Pacific Islander
Hispanic
Latin American/Latinx/Caribbean
Mexican/Chicanx/Xicanx
Other
Military Status:
N/A
Active Duty
Veteran
Discharged
Reserve
Other
Approximate Monthly Income?
How many people (including you) does your income support?
Medical Provider Information
Note: Quest does not provide Primary Care. We recommend that you establish care with a Primary Care Provider (PCP) before your first appointment at Quest.
Primary Care Physician
Medical Center
Location
Phone
Preferred Hospital
Location
Preferred Pharmacy
Emergency Contact
Are you under the age of 18 and/or have a legal guardian?
*
Please Select
Yes
No
Parent/Guardian's Name
*
Emergency Contact's Name
*
Relationship to you
*
Emergency Contact's Phone Number
Alt Phone Number
May we leave a message identifying as Quest?
Please Select
Yes
No
Do they share the same address as you?
Please Select
Yes
No
Address
Street Address
Unit/Apt #
City
State
Zip Code
Sexual Health & Wellness
Current HIV Status:
Please Select
HIV positive
Unknown Status
HIV Negative
Would you like us to contact you regarding confidential HIV testing and/or Support Services?
Please Select
Yes
No
When calling, can we identify as HIV Services?
Please Select
Yes
No
Does your Emergency Contact know your HIV Status?
Please Select
Yes
No
Would you like to receive monthly HIV Services Mailing?
Please Select
Email
US Post
No, thanks!
Do you have CareAssist?
Please Select
Yes
No
Do you identify as a long-term survivor?
Please Select
I certify that the above information is true and accurate:
*
Client/Patient Signature
I certify that the above information is true and accurate:
*
Parent/Guardian Signature
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