Pathway Healthcare Intake Form

1
Let's get started!* This field is required.Which option best describes you?
Referring ProviderNew Patient
2
Patient Name:* This field is required.
Ex: John Smith
3
Patient Phone Number:* This field is required.By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our HIPAA Notice of Provacy Practices. Message grequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.
Ex: 615-585-6985
4
Patient Email Address:* This field is required.
Ex: Johnsmith@gmail.com
5
Patient Zip Code:* This field is required.
Ex: 39735
6
Patient Preferred Method of Contact:* This field is required.
Text
Email
Call
7
Patient Info:
First Name
Last Name
Email Address
Phone Number
Zipcode
Preferred Method of Contact
8
Patient Date of Birth* This field is required.
Date
Year
Month
Day
9
Sex* This field is required.
Male
Female
Undisclosed
10
Will insurance be used?Click next if unsure
YESNO
11
Are you able to upload an current insurance card picture?* This field is required.
YESNO
12
Terms and Conditions* This field is required.Please agree to our T&Cs and sign before uploading
13
Signature* This field is required.Signing below means you agree to provide this sensitive information
Powered by Jotform SignClear
14
Upload Picture* This field is required.Please provide a clear front and back picture of insurance card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Name of insurance being used?* This field is required.
16
Member IDHit next if you are unsure.
17
Payer IDHit next if you are unsure.
18
What services are required?* This field is required.Choose all that apply
Intensive Outpatient Treatment
Psychiatry
Treatment for Substance Use Disorder
Individual Therapy
Family Therapy
Group Therapy
SPRAVATO ®
19
Would you consider telehealth?* This field is required.
YESNO
20
Select your preferred service location:* This field is required.
Columbus, MS
Jackson, MS
Laurel, MS
Birmingham, AL
Huntsville, AL
Jackson, TN
Springfield, TN
21
How did you hear about Pathway?* This field is required.
Referral from Healthcare Provider
Insurance Provider Directory
Family or Friend Recommendation
Psychology Today
Google / Pathway Website
Social Media
Community Event or Health Fair
Employer Wellness Program
Other
22
Which provider referred you?
23
What is the name of your employer?
24
Which social media platform?
25
Referral Info:* This field is required.We want to say thank you!
First Name
Last Name
Email Address
Phone Number
Referring Facility
Should be Empty: