Intake Registration Form
Submit information to start an intake or to update an existing client account.
I am ...
*
..a new client
..a previous client wanting to be seen again
..an existing client updating information
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Date of Birth
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Insurance Plan
*
Medical Asisstance Plan, Blue Plus, UCare PMAP, Health Partners PMAP, Medica PMAP, South Country
Commercial Insurance; BCBS, UCare, Health Partners, UHC/Medica/UMR
I do not have insurance and would like private pay options
Other/Do Not Know
Social Security Number (Optional)
Insurance Plan Name
ID Number
Group Number
Customer /Provider Service Phone Number (back of card) *This is needed for all insurance users*
MA or PMI Number (if applicable)
Are you the Policy Holder?
YES
NO
If you selected NO above please provide the first & last name, date of birth, and relationship to the policy holder.
Insurance Card Front and Back
Browse Files
Drag and drop files here
Choose a file
Submitting photos of your insurance card is the best way to get us all the information we need to verify benefits. THIS FORM IS HIPPA COMPLIANT and is a secure way to send us sensitive information.
Cancel
of
Please provide an Emergency Contact. Include name, relationship to you, and a phone number.
Comments
Who are you looking to see, important information for us to know, overview of things you are experiencing or would like to address with your provider. Feel free to provide as much or as little as you wish.
Please verify that you are human
*
Submit
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