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Demographic Information
Patient's Legal Name:
*
Patient's Legal Name:
First
First
Last
Last
Patient's Chosen Name:
(if different from legal name)
Gender:
*
Female
Male
Transgender (Female-to-Male)
Transgender (Male-to-Female)
Nonbinary
Agender
Genderfluid
Other
Gender:
Pronouns:
she/her
he/him
they/them
she/they
he/they
Other
Pronouns:
Date of Birth:
*
Age:
Social Security Number:
*
Phone Number:
*
Street Address:
*
City:
*
State:
*
Zip Code:
*
County:
*
Employer Name, Address, and Phone Number
(if applicable)
Which PsyCare office or program do you attend?
*
Austintown Clinic
Boardman Clinic
Cortland Clinic
Howland Clinic
Liberty Clinic
Struthers Clinic
Psychiatric Case Management (PCM) Program
Language:
*
Race:
*
White
Black or African American
Asian
Native American, Alaskan Native, Native Hawaiian
Other Pacific Islander
Multiple Race
Decline to Specify
Other
Race:
Ethnicity:
*
Not Hispanic or Latino
Hispanic or Latino
Not Specified
Decline to Specify
Smoking Status:
*
Current
Former
Never
Other
Smoking Status:
Marital Status:
*
Single
Married
Divorced
Widowed
Separated
Other
Marital Status:
Spouse's Name:
*
Date of Birth:
Age:
Phone Number:
Spouse's Employer Name, Address, and Phone Number
(if applicable)
Names and Ages of Household Members:
*
Emergency Contact Name:
*
Relationship:
*
Emergency Contact Address:
Emergency Contact Phone Number:
*
Primary Insurance Name:
Primary Insurance ID Number:
Group Number:
Subscriber Name:
Social Security Number:
Date of Birth:
Subscriber Address:
City:
State:
Zip Code:
Do you have a secondary insurance?
*
Yes
No
Secondary Insurance Name:
Secondary Insurance ID Number:
Group Number:
Subscriber Name:
Social Security Number:
Date of Birth:
Subscriber Address:
City:
State:
Zip Code:
By checking this box, I hereby authorize PsyCare to furnish information to the above insurance carriers concerning diagnosis and treatment and I authorize the insurance carriers to forward all payments to the doctor for services rendered to my dependents or myself. I understand that I am responsible for any charges that are not covered by insurance and that the information provided above is complete and there are no other insurance policies covering services. I understand that it is my responsibility to notify PsyCare Inc of any changes in my insurance coverage otherwise I will be responsible for payments in full. This authorization will be effective as of the date entered below. A photocopy of this authorization shall be considered as valid as the original. This authorization also verifies that I have received and have read the PsyCare handbook and HIPAA notice of privacy practices. I understand that if I have any questions or need clarification, I can ask any member of the PsyCare staff for assistance. I consent to PsyCare providing me with assessment and treatment services.
*
Consent for Treatment
Patient Signature:
*
Clear
Date:
*
If you are human, leave this field blank.
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