Patient Registration Form

Phoenix Integrated Health
New Patient Registration

Please fill in the form below
Registration Date and Time*

MonthDayYear
First Name
Last Name
Address*

Street Address

CityState

Zip Code
Phone Number - Home/Cell*

Area CodePhone Number
E-mail *
Sex*
Date of Birth*

MonthDayYear
Marital Status
State of Residence*
Insurance Information:

By filling this out, I authorize Phoenix Integrated Health the use of the information for the purposes of obtaining third party reimbursement on behalf of the insured.
Social *
Insurance Carrier*
Subcriber ID **
Effective Date **
Take Picture of Insurance Card

Browse Files

Cancelof
Reason for Registration*

Mental HealthAddictionPsychiatristOpioid treatment programsCounselingPhoenix’s Therapeutic Recovery Housing ProgramOther: Specify below
Service Loction*

North Linden-1414 Oakland Park Ave, 432241955 Ohio Drive Grove City, OhioWashington CT HouseHousing Program
Additional Notes
HIM Department Approval
Date

MonthDayYear
Date
Phoenix Representative Name

First NameLast Name
Enter EMR
Chart Number
Referral to
Should be Empty:

Phoenix Integrated Health