SSP Request Appt Form

Who Is Filling Out This Form?*

The PatientParent / Guardian Of Patient

Name Of Individual Filling Out This Form: *

Relation To The Patient: *

(Mother, Father, Aunt, Uncle, Grandparent, etc.)

Patient Name:*

First NameLast Name

Patient Date Of Birth: *

Date

Phone Number:*

Address:*

Street Address

Street Address Line 2

CityState

Zip Code

E-mail:*

example@example.com

Are you an existing or new patient?*

New PatientExisitng Patient

Do you need an online or in-person appointment?*

OnlineIn-person

How were you referred to the practice?

Type Of Insurance: *

We do NOT Accept: Affinity, United Healthcare Community, Fidelis, Medicaid, Health First, Emblem Health GHI, Magnacare, Northwell Direct, JLJ.

Insurance Member ID: *

Are You The Policy Holder?*

YesNo

How Is The Policy Holder Related To You?*

ParentGuardianSpouseOther

Please Describe Why You Are Seeking Treatment: *

Primary Policy Holder Name: *

First NameLast Name

Primary Policy Holder Date Of Birth: *

Date

Preferred Clinician: *

Upload A Picture of the FRONT of Your Insurance Card*

Upload A Picture of the BACK of Your Insurance Card*

Upload A Picture of the License of the POLICY HOLDER *

No other pictures are accepted, must be able to provide a license in order to receive treatment.

Upload A Picture of the License of the PATIENT (If under 16, School ID or Passport ID is acceptable) *

Insurance & Payment Policy:

We are currently NOT accepting:

Affinity, Medicaid, Fidellis, Emblem Health GHI, Magnacare, Northwell Direct, Unitedhealthcare Community, Health First, JLJ-EBCBS.

Out-Of-Network Insurance:

NYSHIP | Beacon | Carelon: We bill out of network, it is your responsilbilty to call your insurance company to see if you have reached your out-of-network deductible. If you have not, you are responsible for any out-of-pocket costs until you have reached your out-of-network deductible. If you are unsure if you have met your out-of-network deductible or not, and would like to know. Click on this link - https://form.jotform.com/240714823999166 - and we will call your insurance for you, before scheduling.

Patient Payment Responsibility:

Patient is responsible for payment for services rendered, and if you have a copay, it will be collected at the beginning of the business day. It is your responsibility to remember your scheduled appointments. South Shore Psychiatry, gives you all the necessary information you need to log-in for your online appointment, links to access specific patient documentation and our office location. South Shore Psychiatry sends you links as well as our software system sends out appointment reminders. If you have more than two consecutive no show appointments, or same day cancelations there is a $75.00 fee associated.

Disclaimer: Please Allow 24-48 Hours For A Staff Member From South Shore Psychiatry To Contact You To Schedule An Appointment.

Request An Appointment With South Shore Psychiatry