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 OneMotherFatherStep-MotherStep-FatherGuardianGrand MotherGrand FatherRelativeOther
Address (required)
Address2
City (required)
State ALAKARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNENHNJNMNVNYNDOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
Zip (required)
Home Phone (required)
Cell Phone
Email Address (required)
Date of Birth (of Parent/Guardian)
Gender (required) Select OneMaleFemale
Drivers License
Marital Status (required) Select OneMarriedSeparatedDivorcedWidowedNever MarriedLiving with Partner
Child lives with this parent Select OneYesNo
Employer
Title
Work Phone Number
Insurance (required) Select OneYesNo- Pay Cash/CC
PRIMARY Insurance Company Name 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
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 Comapny Name 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
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 OneMotherFatherStep-MotherStep-FatherGuardianGrand MotherGrand FatherRelativeOther
Address
Address 2
City
Zip
Home Phone
Email Address
Date of Birth
Gender Select OneMaleFemale
Marital Status Select OneMarriedSeparatedDivorcedWidowedNever MarriedLiving with Partner
Parent Employer
Childs First Name (required)
Childs Last Name (required)
Age of child (required) Select One456789101112131415 or older
DOB (required)
Gender of Child Select OneMaleFemale
