New Patient Registration

New Patient Registration
PATIENT DEMOGRAPHICS
Name*

First NameMiddle NameLast NameSuffix
Birth Date*

MonthDayYear
Gender*

MaleFemale
Age*
Cellphone Number*
Email Address:*
May we text this number?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Info:
Emergency Contact*

First NameLast Name
Relationship*
Contact Number*
Please enter a valid phone number.
INSURANCE
What type of insurance do you have?*

Blue Cross Blue ShieldUnited Health CareUMRAetnaOscarCignaMedicareSelf PayTricareVA Healthcare
Name / Type of Plan
Member ID
Group ID
Provider Phone Number
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Relationship to Insured*

SelfSpouseChildOther
If you are a dependent, please provide primary holder Full Name and Date of Birth
MEDICAL HISTORY
Please provide primary reason for visit (ADHD / Depression / Anxiety / TMS etc.)*
Primary Care Physician

First NameLast Name
Height blanks Weight blank

Are you currently in counseling of therapy?    Type a label

Have you ever been admitted to inpatient for mental health or substance abuse? If so when and where:

Date   Type a label

Date   Type a label
Please list your current medication and dosage.
List all previous Antidepressants
How did you hear about Aware Behavioral Health?*
What is your preferred pharmacy? (CVS, Walgreens etc.) *
PHARMACY NAME AND ADDRESS
Pharmacy Address*
Financial Policy and Consent to Treatment:
We are in network with BCBS, UHC, UMR, Aetna and Medicare (original Medicare); please make sure you have included your insurance information and that we have verified coverage. You may have a copay, coinsurance, or allowable due based on your coverage and this is due at time of service (or before).

Self pay rates are $375 for initial consultation and follow ups are $175. Payments can be submitted via the payment portal on our website or by calling the office.

Please provide 24 hour notice for all cancellations and reschedules via phone, text, or email. We understand things do come up, but please email, text, or call the office as soon as possible so that we can offer your time to someone else. If you do not show up for your scheduled visit or cancel fewer than 24hrs prior, you will be charged a one hundred dollar ($100) FEE; your insurance company will not cover this.

I hereby consent to evaluation, testing, and treatment as directed by my Aware Behavioral health physician or his or her designee.
Authorization for Payment

By signing this form, I authorize the practice to automatically charge my credit/debit card on file for any applicable patient financial responsibility, including but not limited to copayments, coinsurance, deductibles, and any outstanding balances not covered by my insurance. I understand that charges will be processed in accordance with my insurance benefits and applicable services rendered. I acknowledge that I am responsible for any remaining balance and agree to this authorization unless I provide written notice otherwise.
Please take a picture of your driver's license, passport, or ID:
Signature*

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New Patient Registration

PATIENT DEMOGRAPHICS

INSURANCE

MEDICAL HISTORY

Financial Policy and Consent to Treatment: