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Insurance Intake form (new)
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2023-11-14T20:15:17+00:00
Insurance Intake form
This form is required for all clients who are covered by Insurance, EAP, or managed care benefits.
Legal Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Gender:
(Required)
Male
Female
Other
Other
Preferred Pronoun
Social Security #
(Required)
Address
(Required)
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
(Required)
Alternate Contact Phone
Is it alright to leave confidential messages?
Yes
No
Email: Please list the email for the guarantor of the account. Listing your email here constitutes permission to send protective health information via email.
Primary Insurance Company:
(Required)
ID#
Group #:
Insurance Phone number
(Required)
Check one of the following
(Required)
Health Insurance
EAP
Worker's Compensation
Auto Insurance
Name of Primary Insured
Date of Birth
MM slash DD slash YYYY
Your relationship to insured:
(Required)
Self
Spouse
Child/Step-Child
Other
Secondary Insurance Company(if applicable):
ID#
Group #:
Insurance Phone number
Name of Secondary Insured
Date of Birth
MM slash DD slash YYYY
Your relationship to insured:
(Required)
Self
Spouse
Child/Step-Child
Other
I have been given an opportunity to read the Notice of Privacy Practices, and I hereby authorize Psych NW and iMed Billing to provide summary of care and assessment information regarding evaluation and/or treatment for the purpose of evaluating and processing claims for benefits.
I further authorize payment of medical benefits to Psych NW for services provided.
Signed:
(Required)
Name
12. legal sig
Printed name:
(Required)
Name
13. print name
Date
(Required)
MM slash DD slash YYYY
14. todays date
Relationship to Client :
(Required)
Self
Other
Other
Have you been seen by one of our providers before?:
Yes
No
Who referred you to our Office?
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