Annual Patient Information Update

Annual Patient Information Update

Please review and update the information below. Complete all required fields.
Patient Information
Patient Legal Name
Preferred Name
Date of Birth

MonthDayYear
Date
Age
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method(s)
Parent/Guardian Information

(if applicable)
Parent / Legal Guardian Name

First NameMiddle NameLast Name
Relationship to Patient
Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
School Information - For Patients in Grades K–12 Only
Current School
Current Grade
IEP / 504 Status

Other
Insurance and Billing Information
I do not currently have insurance / I am self-pay
Primary Insurance Name
Primary Insurance Member ID
Primary Insurance Group Number
Insured Person’s Name

First NameMiddle NameLast Name
Patient’s Relationship to Insured
Insured Person's Date of Birth

MonthDayYear
Date
Secondary Insurance Name, if any
Secondary Insurance Member ID
Responsible Party Name, if different
Responsible Party Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact and Healthcare Provider Information
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider
If none, please write “N/A.”
Primary Care Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Therapist / Counselor, if any
Therapist / Counselor Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical History Updates
Health or Medication Changes Since Last Intake
New medical diagnoses or major health changes
Medication changes, new side effects, or new allergies/adverse reactions
Surgeries or procedures
ER visits or hospitalizations
Pregnancy or postpartum status
Pregnancy or postpartum details (if Yes)
Acknowledgment and Consent
• I am responsible for deductibles, copays, coinsurance, non-covered services, denied balances, no-show/late cancellation fees, and other patient-responsible balances.

• I authorize Ground Up Behavioral Health to keep and charge a payment card on file according to clinic policy.

• A $50 fee may apply for missed appointments or cancellations/rescheduling with less than 24 hours' notice.

• For minor patients, the adult bringing the patient confirms authority to consent and accepts financial responsibility. Any custody/court orders must be provided before restrictions can be applied.

I certify that the information provided on this update form is accurate and current to the best of my knowledge. I voluntarily consent to treatment and care provided by Ground Up Behavioral Health. I acknowledge that I have read, understood, and agree to the terms above.
Acknowledgment
Patient Name
Parent / Legal Guardian Name (if patient is a minor)
Relationship to Patient
Patient Signature or Parent / Legal Guardian Signature (if patient is a minor)
Date

MonthDayYear
Should be Empty:

Annual Patient Information Update

Patient Information

Parent/Guardian Information

School Information - For Patients in Grades K–12 Only

Insurance and Billing Information

Emergency Contact and Healthcare Provider Information

Medical History Updates

Acknowledgment and Consent