| Patient Information |
Enter patient Full Name*
|
Date: July 31, 2010
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Date of Birth*
(enter as mo/da/year, like 01/31/1900)
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Street Address*
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| City* |
State* |
Zip* |
Home Phone*
(including Area Code, as xxx-xxx-xxxx)
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Work Phone
(including Area Code, as xxx-xxx-xxxx)
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Cellphone
(including Area Code, as xxx-xxx-xxxx)
|
| Email Address |
| Gender*
Male
Female
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Social Security Number*
(enter as xxx-xx-xxxx. If none, enter xxx-xx-xxxx.)
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Parent or Guardian. Or enter Emergency Contact (if different from parent or guardian)*
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Parent or Guardian Address. Or enter Emergency Contact Address (if different from parent or guardian)*
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Parent or Guardian Emergency Phone. Or enter
Emergency Contact Phone (if different from parent or guardian)*
(including Area Code, as xxx-xxx-xxxx)
|
Custodial Parent
(if child is under the age of 18)
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| Is there a "shared" custody order in effect? Yes
No
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If "Yes" please name all parties involved in the order
|
Referral Information |
Who made the referral for services at ACE, Inc?*
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If other than "self", please list the contact name and phone number of the person who made the referral.
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Please list all other agencies involved in the treatment on the patient.
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List names and dates of all previous mental health treatment.
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Educational Placement
|
Insurance Information |
Primary Insurance*
HMO’S (AMERIHEALTH MERCY; GATEWAY HEALTH PLAN; UNISON HEALTH PLAN)
are administered by COMMUNITY CARE BEHAVIORAL HEALTH (CCBH)
NO OTHER MANAGED CARE PLANS ACCEPTED
|
Policy Number*
(if none, enter NONE)
|
ID Number*
(if none, enter NONE)
|
Secondary Insurance (if applicable)
HMO’S (AMERIHEALTH MERCY; GATEWAY HEALTH PLAN; UNISON HEALTH PLAN)
are administered by COMMUNITY CARE BEHAVIORAL HEALTH (CCBH).
NO OTHER MANAGED CARE PLANS ACCEPTED.
|
Policy Number
(if none, enter NONE)
|
ID Number
(if none, enter NONE)
|
Concerning Issues |
Hold down the control key (Ctrl) while clicking to select more than one choice.*
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If you selected "Other", above, please give details here.
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Last treatment received for the indicated issue?*
(if none, enter NONE)
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How long have you been experiencing the issue indicated?*
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Treatment Requesting* |
Hold down the control key (Ctrl) while clicking to select more than one choice.
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Certification |
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By filling in my name and the date, below, and submitting this form I am certifying that the above information is true and correct to the best of my knowledge. I also understand that it is my responsibility to notify ACE Inc staff if there are nay changes to my insurance information. I understand that it is my responsibility for all payments for all services rendered that are not covered by my insurance or other indicated program.
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Enter your full name to certify you have read and agree to the Certification message, above.*
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Enter today's date*
(enter as mo/da/year, like 01/31/1900)
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All copays must be made prior to the session.
Patients with deductibles must make payment arrangements prior to receiving services.
24 hour notification is required for all missed appointments. Failure to make this notification may result in a fee for cancellation or termination of services.
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Enter the two words shown below into the empty box,
then click on 'Send Message'.
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