Psychology Center and Psychologists in Fort Myers, FL, SWFL Psychologists, Dr. Steven Cohen

Patient Registration Form
PATIENT INFORMATION
Patient Name*

First Name Last Name
Birth Date*

Month Day Year
Age*
Under 18?*
Gender*
Marital Status *
Employment Status *
Address*

Street Address

Street Address Line 2

City State

Zip Code
Phone Number*
Alternative Phone Number
Email Address - Used for Patient Portal invitation and appointment reminders. Do not use junk email*
Reason For Visit*
Our office is dedicated to providing the best care possible, this section is to help get you placed with the best fit Doctor, please include more than I have a referral or I would like become a new patient. We need to know why you are seeking help/treatment
Referred by:
Office Location - please indicate which office you would prefer to be seen

Fort MyersNaplesTelehealth
Preferred Provider

Dr. Steve CohenDr. Candice HurstDr. Beth A. HowlettDr. Marisa BermudezDr. Glen MillerDr. Keysha KrenDr. David RawlingsDr. Linda WilmshurstDr. Alexander JaffeDr. Nicole CantorFirst AvailableMost Appropriate
Health Insurance information
I Would Prefer To Self Pay*
Only Enter YES if you DO NOT want to use insurance to pay for treatment. Self Pay Rates are $220.00 for first visit, $200.00 for returning
Insurance Provider

Blue Cross Blue ShieldOptum (formally United Behavioral Health or United Health Care)AetnaCignaMedicare (Please include secondary if applicable)Web TPAValue OptionsAllegianceMeritainGolden RuleUMROther - Please call office to confirm we are in network with your provider (not contracted with ANY Medicaid)
Member ID
This is required to pull your insurance benefits
Provider Services Phone Number
This is usually a 800 number located on the back of your insurance card
Secondary Insurance Provider and Member ID - If Applicable
Policy Holders Name (If different than patient)
Policy Holders Date of Birth

Month Day Year
Policy Holders Relationship to Patient
PARENT/LEGAL GUARDIANS
Please complete the following section if patient is under 18 years old or is under legal guardianship

If you are an adult completing this for yourself skip to submit form
1st Parent / Legal Guardian Name

First Name Last Name
Parent / Legal Guardian Birth Date

Month Day Year
Phone Number

Area Code Phone Number
Address (if different)

Street Address

Street Address Line 2

City State

Zip Code
2nd Parent / Legal Guardian Name

First Name Last Name
Parent / Legal Guardian Birth Date

Month Day Year
Phone Number

Area Code Phone Number
Address (if different)

Street Address

Street Address Line 2

City State

Zip Code
DateTime
Should be Empty:

Patient Registration Form

Health Insurance information

PARENT/LEGAL GUARDIANS