Adult New Patient Request Form

Ages 18 & Over

Please correct the errors described below.

Step 1 for New Patient Intake

Thanks for choosing Mental Health Baltimore, LLC for your care. Once you complete this form it is automatically received. We will complete a benefits verification and proceed with the next steps for new patient intake

Legal First and Last Name

Preferred Name and Pronouns

Legal Gender

Your Birthday

Cell Phone Number

Email address

Home Address to include City, State, and Zip Code

Emergency Contact First and Last Name

Select Your Primary Insurance

Aetna

Commercial

BCBS

Commercial

Cigna

Commercial

Medicaid

All MCO's accepted

Medicare

United Healthcare

Commercial

Upload the Front of your Primary Insurance Card

Add file

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Select Your Secondary Insurance

Aetna

Commercial

BCBS

Commercial

Cigna

Commercial

Medicaid

All MCO's accepted

Medicare

United Healthcare

Commercial

None

Upload the Front of your Secondary Insurance Card

Add file

Please upload a file

How were you referred?

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Step 1 for New Patient Intake

Electronic signature

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