Patient Registration Form

Patient Registration Form

Kirkbride Center 111 North 49th Street Philadelphia PA 19139
IF YOU ARE IN CRISIS PLEASE CALL 911!

If you have a medical emergency, call 911 right away or go to the nearest emergency room. Online messages and chats are not monitored for emergencies or life-threatening conditions.

For immediate mental health or crisis support, call or text 988 to reach the Suicide and Crisis Lifeline.

Lastly, this form is for setting up a telehealth session with a licensed Therapist at Kirkbride. If you do NOT wish to consent to this and share a valid phone number and/or email address, please call 215-471-2600 to speak to a representative.

Version 1.0 23 June 2026
General/Visit Info
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Care Provider
Referral Source (for example, who told you about us?)
How did you hear about us?
Patient Demographics
Name

First NameMiddle NameLast NameSuffix
Last Name
First Name
Middle/MI
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex
Marital Status
Maiden Name
Identity Verification Number
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email this is required for Telehealth Session
example@example.com
Driver's License State and Number
Sexual Orientation
Sexual Orientation
Gender Identity
Gender Identity
Hispanic or Latino?
Ethnicity
Race
Language
Emergency Contact
Please select if you want to provide an Emergency Contact now or not.
Emergency Contact's Full Name

First NameLast Name
Emergency Contact's Relationship to Patient
Emergency Contact's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact's Primary Phone Type
Emergency Contact's Email
example@example.com
Emergency Contact's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I,{q9_textbox7} {q8_textbox6} authorize Kirkbride Center to release/obtain the specific information below to:

1. Emergency Contact: {q29_fullname27}
2. Relationship to You: {q30_textbox28}
Contact Number: {q32_phone30}

The specific information that is to be released is: (Information that identifies a client as a participant in substance abuse treatment, including dual diagnosed clients is covered at 4 Pa. Code § 255 (b) and is restricted by law to the following):
The purpose of this disclosure is:
180 days from Today Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Information covered by Act 148 related to HIV shall not be released without a separate release form. This authorization is subject to verbal or written revocation at any time except to the extent that action has been taken in reliance thereon. This authorization will expire 180 days after the date of my signature and will begin on {todaysDate172} and end on {date}. This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR Part 2) and Pennsylvania Act 33. The federal rules allow the recipient to re-disclose this information in accordance with the HIPAA regulations for treatment, payment, and health care operations. However, the federal rules restrict any use of this information to criminally investigate or prosecute any patient with a substance use disorder.
I would like a copy of this consent upon arrival to Kirkbride
I understand the nature and the use of the information to be released.
Patient Name

First NameLast Name
Signature
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of or any use of the information is not sufficient for this purpose.
Financially Responsible Party
Who will be financially responsible for you?
If you chose "Someone else" please enter their name below:

First NameLast Name
Relationship to Patient
Other Person's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Type
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address Line 1
Address Line 2
City
State
Zip
Responsible Party Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance & Payment
Method of Payment
Patient's relationship to Primary Subscriber

Other
Primary Insurance Company
Primary Insurance Plan
Primary Policy Number/ID
Primary Group Number
Primary Co-payment
Primary Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insurance Company Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Subscriber/Policy Holder Full Name

First NameLast Name
Primary Subscriber Sex
Primary Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Subscriber Tax ID
Primary Subscriber Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Do you have a Secondary Insurance?
Secondary Insurance Company
Secondary Insurance Plan
Secondary Policy Number/ID
Secondary Group Number
Secondary Co-payment
Secondary Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insurance Company Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Subscriber/Policy Holder Full Name

First NameLast Name
Secondary Subscriber Sex
Secondary Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Subscriber Tax ID
Secondary Subscriber Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Patient's relationship to Secondary Subscriber

Other
Reason unable to provide insurance information
Pharmacy Information
Preferred Pharmacy
Pharmacy Address
HIPAA Communication Preferences
Due to the new federal patient Confidentiality Laws (HIPAA). Kirkbride Center will need your permission to do the following:
Confirm appointments
Leave messages with anyone or on voicemail/answering device
Leave lab results with anyone or on voicemail/answering device
HIPAA permissions date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HIPAA patient name

First NameLast Name
BY SIGNING BELOW I FULLY UNDERSTAND THAT I AM GIVING KIRKBRIDE CENTER, PERMISSION TO DO THE ABOVE.
Patient signature
Staff witness signature
Telehealth Consent
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine/telehealth services, and that no information obtained in the use of telemedicine/telehealth services which identifies me will disclosed to other entities without my consent.

2. I understand that I have the rights to withhold or withdraw my consent to the use of telemedicine/telehealth in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine/telehealth interaction, and may receive copies of this information for a reasonable fee.

4. I understand that a variety of alternative methods of medical/health care may be available to me, and that I may choose one or more of these at any time. My doctor/therapist has explained the alternatives to my satisfaction.

5. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

6. I understand that insurance coverage of telehealth sessions may differ based on my insurance plan. It is in my best interest to check with my insurance company regarding the coverage.

7. I understand that I am fully responsible for co-payments and deductible amounts, and that I am fully responsible to pay the provider if telehealth/telemedicine sessions are not covered by my insurance company1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine/telehealth services, and that no information obtained in the use of telemedicine/telehealth services which identifies me will disclosed to other entities without my consent.

Patient Consent to the Use of Telehealth/Telemedicine Services

I have read and understand the information provided above regarding telehealth/telemedicine services, have discussed it with my physician/therapist, and all of my questions have been answered to my satisfaction. I hereby give consent for the use of telehealth/telemedicine services in my care. I hereby authorize Kirkbride Center to use telehealth/telemedicine services during my diagnosis and treatment.
Telehealth Consent Patient Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Legal Guardian if needed

First NameLast Name
Patient or Parent/Legal Guardian Signature
Offered copy (patient's initials)
Authorization to Disclose/Obtain Information
I hereby authorize Kirkbride Center to disclose/ obtain protected medical information as described below from the records of:
Name

First NameLast Name
Patient Name (Last, First, Middle Initial)
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
To be disclosed to / obtain from:
Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone #
Please enter a valid phone number.Format: (000) 000-0000.
Fax #
Please enter a valid phone number.Format: (000) 000-0000.
Reason for disclosure / obtaining information
Coordination of care
I understand that:
This authorization may be revoked at any time by writing, except to the extent that information has already been disclosed. If information has already been disclosed in reliance on this authorization revoking it will only prevent further disclosure.
subject to re- disclosure by the individual /organization identified
- lnformation (except drug and alcohol information) disclosure pursuant to this authorization may be used by Kirkbride Center
- Kirkbride Center and its designee are hereby released from any legal responsibility or liability for disclosure of the specified information
- The Authorization may include Mental Health, Drug & Alcohol Abuse and or HIV related information
The information to be disclosed: *****Check the box next to information you wish to have disclosed.
Information Type
(Two years from today.)
Authorization Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Today's Date for calculatation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization End Date (calculated for two (2) years from Authorization Start Date)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Client / Personal Representative
Date of Client / Personal Representative Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Guardian Signature
Date of Guardian Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness Signature
Date of Witness Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Representative Name if not signed by Patient
Relationship to Client if not signed by Patient
Informed Consent to Treatment
I have voluntarily chosen to receive treatment with Kirkbride Center or contractors (Provider), in a good therapeutic relationship. It is considered my right as well my duty to ask any questions and fully discuss the risks and benefits of any proposed treatment. It should also include the risks & benefits of any alternate treatment/or no treatment.
Patient's Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's/Representative's Signature
Acceptance of Financial Responsibility
I take full responsibility of the financial liability for the proposed services provided. I understand that the time is reserved in advance. If I don't give at least 24-48 hours notice to cancel, I may be charged $70- $150. I'm responsible for co-pay, coinsurance, deductible, & non-covered service.

There is a $5 charge for late payment of co pay. We charged $30 for any bounced bank check. I allow Kirkbride Center and its associates to bill my insurance company.
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient/Representative Signature
Medical Records Release
Medical Records Release etc
I understand that the confidentiality of my records is protected, and release of information will be only by my written consent. Exceptions to confidentiality are as follows:

a) local and state law may require reports of cases of child/minor/elderly abuse or neglect;

b) if there is danger to self or others.

c) Court order.

I understand that all records pertaining to my treatment may be released to my insurance company for claim processing, utilization review purposes, quality management or grievance/appeal process etc.
Patient's Name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's/Representative's Signature
Guardian Section (If Applicable)
Guardian's Name

First NameMiddle NameLast Name
Guardian's Signature
Guardian's Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Patient Registration Form

General/Visit Info

Patient Demographics

Emergency Contact

Financially Responsible Party

Insurance & Payment

Pharmacy Information

HIPAA Communication Preferences

Telehealth Consent

Authorization to Disclose/Obtain Information

Informed Consent to Treatment

Acceptance of Financial Responsibility

Medical Records Release

Guardian Section (If Applicable)