Medication-Assisted Treatment (MAT)- New Patient Form
Please fill out your form as completely and accurately as possible. Information collected on this form will only be used by TriState Health to register for your appointment unless stated otherwise and approved with your clear written consent.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
OK to leave a message?
*
Yes
No
Insurance Information
PRIMARY INSURANCE INFORMATION
Primary Insurance
Primary Subscriber Name
Primary Subscriber's Relationship to Patient (If you are the primary subscriber, please write "self.")
Primary Subscriber's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Insurance ID # (include alpha prefix, if applicable)
Primary Group #
MAT Questions
Are you currently taking Suboxone or Subutex?
*
Yes
No
Are you currently using any substances?
*
Yes
No
Please list what substances and the date of last use below:
Please list the date of last use and what substance below:
Are you currently involved with outpatient treatment or counseling?
*
Yes
No
Do you have any legal issues (pending charges, probation/parole, etc.)?
*
Yes
No
Please explain.
Communication
Please read statement regarding TriState communications and choose one option.
I hereby authorize TriState Health to contact me via my provided email for TriState related marketing communications. Treatment is not conditioned upon my authorization to agree to receive marketing communication and my authorization shall remain effective until canceled by me in writing to TriState Health.
I agree
I do not agree
Market Research Questions
**OPTIONAL: Please answer one question below about how you heard about TriState Health.
How did you hear about us? Please choose all that apply:
Word of Mouth
TV Commercial
Lewiston Morning Tribune
Website
Billboard
Community Event
Facebook
Other
Please list below what other way you heard about us:
Submit
Should be Empty: