New Patient Questionnaire

INTEGRAL HEALTH ASSOCIATES
Document Submission Form
Please be aware that this inbox is only used to receive documents (e.g. ID, copy of insurance card, etc.) and IS NOT monitored regularly. If you are submitting any specific forms, please inform your clinician ahead of time.
Name of Patient*
Patient Date of Birth:

MonthDayYear
Name of Person Submitting Form*
Phone Number of Person Submitting Form*
This is for:

Richard Yun, MDAmy Catalano, PsyDAndre Philipp, APRNGoetti Francois, APRNKate Pfeiffer, APRNFrancine Lombardi, LCSWOffice StaffOther
Description of File(s) Uploaded:

Copy of ID and/or insurance cardDocument(s) for clinicianOther
Please upload files:*

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Date

MonthDayYear
Date
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When you are finished, please click the submit button below.
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Document Submission Form