Bay Psychiatric Associates - Referring Provider New Patient Form

What is the primary service of interest?
For all Inpatient services, please contact Herrick Hospital directly at 510-204-4040.
For all Day Treatment services (PHP & IOP), please contact Herrick Hospital directly at 510-204-4040.

First Name
Last Name
Email
Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Sex
Gender Identity
If your primary residence is out of the state of CA, we are unable to see you because our physicians are licensed in the state of CA
Address

Street Address

Street Address Line 2

CityState (put CA for California)

Zip CodeCountry
Location of interest?
Were you Referred to Us?
HIDDEN: Were you Referred to Us?
Are you a referring provider?
Referring Provider Name
Referring Provider Phone
Format: (000) 000-0000.
Referring Provider Email
example@example.com
Referring Provider Healthcare Group
Contact Person at Office
Do you have a preferred BPA physician you would like your patient to see?
Any notes, comments, questions?

0/255

Insurance Provider
If you are a Kaiser member, you will need to obtain an authorization referral for medical psychiatry services before you can be scheduled.
Insurance ID Number (please include any alpha-prefixes)
Group Number
Insurance Subscriber Name
Insurance Subscriber Date of Birth

MonthDayYear
Provider Services Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please Upload Photos of Front and Back of Insurance ID Card

Cancelof
Do you have Secondary Insurance?
Secondary Insurance Provider
Secondary Insurance ID Number