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!
Primary Parent First Name (required) of Parent/Guardian
Primary Parent Last Name (required) of Parent/Guardian
Relationship (required) Select One Mother Father Step-Mother Step-Father Guardian Grand Mother Grand Father Relative Other
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
Email Address (required)
Date of Birth (of Parent/Guardian)
Gender (required) Select One Male Female
Drivers License
Marital Status (required) Select One Married Separated Divorced Widowed Never Married Living with Partner
Child lives with this parent Select One Yes No
Employer
Title
Work Phone Number
Insurance (required) Select One Yes No- Pay Cash/CC
PRIMARY Insurance Company Name 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
Policy Holder Name as on insurance card
Policy Holder DOB
Member ID # as on insurance card
Group # as on insurance card
Payor ID (EDI Number) often on back of card
Effective Date
Insurance Phone Number often on back of card
SECONDARY Insurance Company Name Select One Aetna All Savers Assurant Health Baylor Scott & White Beech Street - PPO Blue Cross Blue Shield - PPO & HMO Boon-Chapman Cigna GEHA Golden Rule GPA Group & Pension Some Health Smart plans Health Partners Humana Choice PPO Meritain Health MultiPlan PHCS Texas True Choice TML UMR United Health Care PPO Web-TPA
Policy Holder ID # as on insurance card
Policy Holder Group # as on insurance card
Insurance Phone #
Required if child is covered under parent's insurance provider
First Name
Last Name
Relationship Select One Mother Father Step-Mother Step-Father Guardian Grand Mother Grand Father Relative Other
Address
Address 2
City
Zip
Home Phone
Email Address
Date of Birth
Gender Select One Male Female
Marital Status Select One Married Separated Divorced Widowed Never Married Living with Partner
Parent Employer
Childs First Name (required)
Childs Last Name (required)
Age of child (required) Select One 4 5 6 7 8 9 10 11 12 13 14 15 or older
DOB (required)
Gender of Child Select One Male Female
