Intake form - Mark Erickson, LCPC, LIMHP, LPC
Gathers family demographic and insurance policy information.
Therapist name
...if known
First Name
Last Name
Client information
Who is the client?
*
First Name
Last Name
Gender
*
Male
Female
Date of birth
*
-
Month
-
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Responsible Party
Who will be responsible for paying the therapy bill?
*
Client
Another person
Family member who will be financially responsible
First Name
Last Name
How is the Responsible Party related to the client?
Parent
Parent in-law
Spouse
Significant other
Sibling
Grandparent
Child
Child-in-law
Grandchild
Other
Gender of Responsible Party
Male
Female
Date of birth of Responsible Party
-
Month
-
Day
Year
Is Responsible Party's address the same as client?
Yes
No, different address
Mailing address of Responsible Party
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address of Responsible Party
*
example@example.com
May we contact the Responsible Party at this email address?
*
Yes
No
Other ways to contact Responsible Party
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Primary insurance coverage
Is there insurance coverage?
*
Yes
No
Who is the primary insurance carrier?
Employee Assistance Program (EAP)
Medicare / Medicare Advantage / Railroad Medicare
Medicaid (Check only if no other insurance)
Aetna
Allied Benefit Systems Inc.
AllSavers
Ambetter
Assurant Health Self-Funded
Auxiant
BCBS
Centivo
Cigna
ChampVA
Elite Choice
EMC Risk Services
First Choice Health
Golden Rule
Gravie Administrative Services
Group & Pension Administrators
Health Partners
Humana
Medica Behavioral Health
Medico Insurance Company
Meritain Health
Mid American Benefits
Midlands Choice
Surest
TriCare (for Active members)
TriCare for Life (for retired members)
UMR
United Healthcare / United Behavioral Health / Optum UBH
UnitedHealth Shared Services
UnitedHealthcare Student Resources
VA CCN (special plan for military families)
Wellmark HMO
Other primary carrier
What is the name of the other primary carrier?
Employee Assistance Program
Which EAP?
Anthem
ComPsych
Curalinc
UBH EAP
Other EAP
What is the name of the other EAP?
How many free sessions are you allowed?
Medicare plan
What type of Medicare plan is this?
Regular Medicare
Railroad Medicare
AARP Medicare Complete
UHC Medicare Advantage
United Healthcare Dual Plan
Other Medicare plan
What is the other Medicare plan?
Insurance card information
Primary Insurance Policy Id
Group# - if applicable (Never needed for Medicare or Medicaid)
Employer
Policyowner (the name is on the insurance card)
First Name
Last Name
Has this person's information already been entered on this form?
Yes
No
Policyowner
How is the Policyowner related to the client?
Parent
Parent in-law
Spouse
Significant other
Sibling
Grandparent
Child
Child in-law
Grandchild
Other
Gender of Policyowner
Male
Female
Date of birth of Policyowner
-
Month
-
Day
Year
Has Policyowner's address already been entered on this form?
Yes - same as Client
Yes - same as Responsible Party
No
Policyowner's address
Address of Policyowner
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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OTHER INSURANCE
Medicare supplement
Is there a Medicare supplement?
Yes
No
Who is the Medicare supplement carrier?
AARP
BCBS
Cigna
Mutual of Omaha
United Healthcare
Other carrier
What is the other supplement?
Medicare Supplement Policy Id
Specify any Medicaid coverage
Medicaid Policy Id
For Nebraska residents
Molina Healthcare of Nebraska
Nebraska TotalCare
United Healthcare Community Plan
For Iowa residents
AmeriGroup Iowa
Iowa TotalCare
Wellpoint
Other policies
Any other insurance coverages you have not identified?
Provide claim address, policy owner, policy Id and any other information that could be helpful.
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All done!
Submit
Should be Empty: