Patient Intake Form
Complete this section with the patient's information and intake details.
Referral
Please enter information about your referral in the space below.
Did someone refer you for testing or therapy?
*
Please Select
Yes
No
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Who referred you for testing?
*
Where does the person who referred you work?
*
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Who are you in relation to the patient?
*
Please Select
I am the patient
I am the parent or legal guardian
I am not the parent or legal guardian, but I have the legal authority to make healthcare decisions on the patient's behalf.
I do not have the legal authority to make healthcare decisions on behalf of the patient
If the patient is over the age of 18 and doesn't have a legal guardian, they must fill out this form as the patient.
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Sorry we need an authorized person to fill out the form.
*
Please have someone with legal authority to consent to this psychological evaluation for the patient fill out this form.
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Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Patient's Name
*
First Name
Middle Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
Date
Patient Age
*
Parent / Guardian Name
*
First Name
Last Name
Patient Address (If Multiple, put address associated with Patient's Insurance Plan)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent / Guardian Email Address
*
example@example.com
Who is filling out this form?
*
First Name
Last Name
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Sorry, your child is too young to do testing with us right now.
*
We are sorry. We do not currently accept patients under the age of 5 at this time. Please contact us around your child's fifth birthday and we will get him on the schedule.Â
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Insurance Questions
How do you pay for the testing or therapy services?
Out of pocket / self-pay
I plan to use United Healthcare, Optum, UMR, Tricare to pay for services.
I plan to use my Blue Cross Blue Shield, Medicare, Aetna, Cigna, Humana, Medcost, or Medicaid benefits to pay for testing or therapy.
I plan to use another insurance payer to to pay for the services.
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By signing, I authorize Collin Testing and Psychological Services PLLC to bill my insurance plans outlined in this document for the services rendered.
*
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Which of the following best describes your insurance?
I have Medicaid and at least one other insurance (likely Medicare or from your employer or a family member's employer)
I only have Medicaid and no other insurance plan
I do not have Medicaid
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Do you have Medicare?
Yes
No
Please upload the front of your Medicare Card
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Please upload the back of your Medicare Card
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Do you have a supplemental Medicare or Medicare advantage plan through a commercial insurance company or do you just have Medicare?
Yes
No
What is your commercial insurance company?
Blue Cross Blue Shield (BCBS)
Aetna
Cigna
Medcost
Other
Please upload the front commercial insurance card here
*
Upload Insurance Card
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Choose a file
You should be uploading the front of your BCBS, Aetna, Medcost insurance card it doesn't upload, try taking a screen shot of the picture and uploading the screenshot
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Please upload the back of your insurance card here
*
Upload Insurance Card
Drag and drop files here
Choose a file
You should be uploading the back of your BCBS, Aetna, Medcost insurance card it doesn't upload, try taking a screen shot of the picture and uploading the screenshot
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If you selected other to the previous question, please list payer here:
Member ID on card
*
Retype Member ID
*
Do you have North Carolina Medicaid coverage?
Yes
No
*
A valid credit or debit card is required to book your appointment. What is the credit or debit card type?
*
Please enter credit card type (e.g., Visa, Amex, Mastercard)
What are the last four digits of the credit or debit card?
*
By signing below I agree to the practice billing my card for the services rendered.
*
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You either chose to do self-pay OR we do not accept your insurance plan. Would you like to proceed by paying out-of-pocket? (Standard rates apply: $200/therapy session or $2,400/evaluation)
Yes
No
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If the cost is too high, we offer a limited number of sliding scale slots based on financial need. Would you like to be considered for a reduced rate?
Yes
No
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What is your estimated household income?
Under $50,000
$50,001 - $80,000
$80,001 - $110,000
Over $110,000
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Your sliding scale rate is $2,000 for a psychological evaluation and $165 per therapy session. Would you like to proceed?
*
Yes
No
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Your sliding scale rate is $1,600 for a psychological evaluation and $135 per therapy session. Would you like to proceed?
*
Yes
No
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Your sliding scale rate is $1,200 for a psychological evaluation and $100 per therapy session. Would you like to proceed?
*
Yes
No
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We are sorry.
*
We apologize that we were unable to help you.
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*
*
A valid credit or debit card is required to book your appointment. What is the credit or debit card type?
*
Please enter credit card type (e.g., Visa, Amex, Mastercard)
What are the last four digits of the credit or debit card?
*
*
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What Medicaid insurance company do you have?
Vaya Health
Partners
Carolina Complete Health
Amerihealth Caritas
Healthy Blue
United Health Care Community Plan
Other
If you selected other, what is the name of the payer?
Please upload a picture of the Front of your Medicaid Card.
*
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Choose a file
This card should be HealthyBlue, Amerihealth Caritas, Vaya Health, or Carolina Complete Health. If your card will not upload, please take a screen shot of the photo and upload the screen shot.
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of
Please upload a picture of the BACK of your Medicaid Card.
*
Browse Files
Drag and drop files here
Choose a file
This card should be HealthyBlue, Amerihealth Caritas, Vaya Health, or Carolina Complete Health. If your card will not upload, please take a screen shot of the photo and upload the screen shot.
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of
By signing, I agree to the above terms and conditions and consent to the services.
*
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*
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After you click Submit you will be redirected to our scheduling portal to schedule your appointment.
After you click submit, do not close your browser.
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