TGH Patient Information Form
* Indicates a required field
Provider Name
*
Please Choose One
Amelia Psychological Services LLC
Amy Small LCSW
Angela D. Turner, LMHC
Anthony Tanona, Psy.D.
Beth Liljestrand, LMHC MS, EdS
Christina Remek, Psy.D.
Dawn C Holiday-Bruner MA, LMFT
Debra Weaver, Ph.D
Gina M Harris, Ph.D.
Gretchen White, LCSW Ph.D
Help for Wellness
Isabel Alfonso, Ph.D.
James Gagnon, Ph.D. LCSW
Jennifer Sanderson. Psy.D
Jill Rosen, LCSW
John T. Miele, Ph.D.
Kalon Christian Counseling
Karol Brigham, Ph.D.
Kathryn Scrivener, LCSW
Kristi Damron, LCSW
Linda Brant, Ph.D.
Linda Enfinger, RN, MSW
Linda Sarvis, LCSW
Lori Conroy, MS, LMFT
Luisa Peralta, Psy.D.
Dr. Melody Midoneck
Nicole Swaggerty-Valdes, Ph.D.
P. Daniel Knabb, Ph.D
Patricia Dixon, LCSW
Patricia Prickett, MFT
Rich Greete, LMHC
Sanaa Mrabet,Psy.D.,
Stephen L Wright, Ph.D.
Theresa Ellis, LCSW
Tracy Bane, LCSW
Name
*
First Name
Last Name
Patient DOB:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code / + 4
Email
*
example@example.com
Do you want to be notified of your benefits?
Yes
No
Primary
Primary Insurance Company Name
*
Primary Insurance Company Phone Number:
*
-
Area Code
Phone Number
Primary Insurance Card I.D. # / Subscriber #:
*
Primary Group #:
Primary Policyholder's Name:
*
First Name
Last Name
Primary Policy Holders DOB
*
Primary Client's Relationship:
*
Self
Spouse
Child
Primary Policyholder's Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a Secondary Insurance?
*
Yes
No
Secondary
Secondary Insurance Company Name:
Secondary Insurance Company Phone Number:
-
Area Code
Phone Number
Secondary Insurance Card I.D. # / Subscriber #:
Secondary Group #:
Secondary Policyholder's Name:
First Name
Last Name
Secondary Client's Relationship:
Self
Spouse
Child
Secondary Policyholder's Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I authorize the release of any confidential medical information necessary to process my medical claims and for the continuation of treatment to the insurance carriers as required by them. I understand that I am required to pay any health insurance deductible, co-insurance, or any other charges incurred which are not paid by my insurers or any third party payers.
*
Yes
Submit
Should be Empty: