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	Country

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
If you know someone who is currently being treated at one of our offices please include their name and relationship to you
Ex. Name, Relationship
Referred by:
Office Location - please indicate which office you would prefer to be seen

Fort Myers Naples
Preferred Provider

Dr. Steve Cohen Dr. Candice Hurst Dr. Natalia Vallejos Dr. Linda Wilmshurst Dr. Marisa Bermudez Dr. Glen Miller Dr. Beth A. Howlett First Available Most 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 $190.00 for first visit, $170.00 for returning
Insurance Provider

Blue Cross Blue Shield Optum (formally United Behavioral Health or United Health Care) Aetna Cigna Medicare (Please include secondary if applicable) Web TPA Value Options Allegiance Meritain Golden Rule UMR Other - 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	Country

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	Country

DateTime
Should be Empty:

Patient Registration Form

Health Insurance information

PARENT/LEGAL GUARDIANS