Patient Registration Form

Phoenix 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 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, 43224
Additional Notes
HIM Department Approval
Date

MonthDayYear
Date
Phoenix Representative Name

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

Phoenix Health