Schedule First Visit
Hello and Welcome!
Please take a moment to review and fill out the new patient application form below. Submitting this form prior to your first appointment will ensure your prompt attention upon arriving. Our goal is to provide you and your family with excellent medical treatment along with our friendly, courteous service. Thank you again for choosing our physician associates, for specialized and exceptional ADD/ADHD healthcare!
First Name (required)
Last Name (required)
Address (required)
Address2
City (required)
State AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
Zip (required)
Home Phone (required)
Cell Phone (required)
Email Address (required)
Drivers License
Date of Birth
Marital Status (required) Select One Married Separated Divorced Widowed Never Married Living with Partner
Patient Employer (required)
Referred By (required) Select One Doctor Relative School Hospital Friend Google Yahoo MSN
Employer
Title
Work Phone Number
Insurance (required) Select One Yes No
Provider Select One Aetna ( EXCEPT some EPO plans) All Savers Assurant Health Baylor Scott & White Beech Street - PPO Blue Cross Blue Shield - PPO & some HMO's Boon-Chapman Cigna ( Except Focusin ) GEHA Golden Rule GPA Group & Pension Some Health Smart plans Health Partners Humana Choice PPO Meritain Health MultiPlan - (most products ) PHCS (most products) Texas True Choice TML UMR United Health Care PPO ( we're TIER 2 Specialists & NOT in network w/ Compass or Navigate ) Web-TPA
Employer of Policy Holder
Policy Holder First Name
Policy Holder Last Name
Policy ID Number (As on insurance Card)
Group Number (As on insurance Card)
Payor ID / EDI Number
Policy Holders DOB
Effective Date
Insurance Phone #
Secondary Insurance Yes No
Secondary Providers
Policy Holders Name (As on insurance Card)
