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 ALAKARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNENHNJNMNVNYNDOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
Zip (required)
Home Phone (required)
Cell Phone (required)
Email Address (required)
Drivers License
Date of Birth
Marital Status (required) Select OneMarriedSeparatedDivorcedWidowedNever MarriedLiving with Partner
Patient Employer (required)
Referred By (required) Select OneDoctorRelativeSchoolHospitalFriendGoogleYahooMSN
Employer
Title
Work Phone Number
Insurance (required) Select OneYesNo
Provider Select OneAdmar/Med NetworkAetnaAmeriBenBlue Cross Blue ShieldCignaCCNHealth Management Network, Inc.Medical ControlPrincipal LifePrincipal Edge Network PPOUnited Health CareUSA Managed Care OrganizationWeb-TPAAssurant HealthBCBS - PPO/POSBeech Street-PPOBoon-ChapmanCare Improvement Plus of TexasChoiceCare NetworkGalaxy/Managed Care Inc.Golden RuleGreat West POSGreat West PPOGreat West - All productsGroup ResourcesGroup & PensionGuardianHealthSmart NTHN -Gated EPOHealthSmart NTHN - POSHealthSmart NTHN-PPOHealth PartnersHumana Choice PPOHumana Preferred NetworkImericaIndependentMedical Systems(IMS)Cash/Self PayIndependent Medical Systems(IMS)PPOInterplan Health Group (Accountable Health Plans)MultiPlan/PHCSMultiPlan Inc-PPOPacifiCare-PPOPHCS (most products)PlanVista Solutions-PPOPRONextPrincipal FinancialPrivate Healthcare Systems-PPOProvider Select, Inc.QualChoiceTexas True ChoiceTMLUMRUniCareUnited-Non-PPOUnited-options PPOUSA Mgd. Care Organization-PPO
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 YesNo
Secondary Providers
Policy Holders Name (As on insurance Card)
