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By ACMEAdmin|2020-01-30T22:17:23+00:00January 30th, 2020|Uncategorized|1 Comment

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Intake Form

Step 1 of 3 - Patient Details

33%

Are you currently experiencing thoughts of suicide?

Yes

Patient Details

Patient First Name(Required)

Patient Last Name(Required)

Are You a:(Required)

Minor

Adult

Home Phone

Work Phone

Mobile Phone

OK to Leave a Message?

Yes

Text

Call Only

Patient Speaks

English

Spanish

Patient Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Referred By

Name of Parent or Legal Guardian(Required)

First Last

Insurance Info

Name of Insured(Required)

Insured SS #(Required)

ID Number(Required)This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

State issued(Required)

Upload a photo of your ID (optional)This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Name of Insurance(Required)

Insurance Co. Phone(Required)

Upload photo of insurance card front(Required)This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Upload photo of insurance card back(Required)This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Are You In Network?(Required)

Yes

Not Sure

Has Patient Been Seen Yet?

Yes

Benefits 1 of 2

Is Provider In Network?

yes

Type of Service Requested

EAP

Mental Health

Adolescent

Individual

Couples

Family

Type of Appointment Preferred

Select Your Desired Location(Required)

Effective Date

MM slash DD slash YYYY

Additional NotesExample – Do Mental Health Benefits carve out?

Claims Mailing Address

Street Address Address Line 2 City State ZIP Code

Patient Signature(Required)

Parent or Legal Guardian Signature(Required)

Date

MM slash DD slash YYYY

Submit Your Resume

Upload you resume with cover letter stating areas of interest. (population and geographic locations)

First Name(Required)

Last Name(Required)

Preferred method of contact(Required)

Phone

Either is fine

Phone(Required)

Email(Required)

Attach your cover letter stating your areas of interest(Required)

Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.

Attach your Resume(Required)

Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.

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