New Client Request for Services

Attention:

If this is a request for an urgent response, please call 517-667-0061. We will get back to you as soon as possible. If this is an emergency, please call 911 or go to your nearest emergency room.

First Name

Middle Init

Last Name

Date of Birth

Mobile Number

You may get appt reminder texts at this number

May we text you at this number

Yes No

Email address

Address

City

State

Zip Code

Client Guardian

Client Sex

Male Female

Policy Type

Commercial or Marketplace Medicaid Medicare

Insurance Company

Policy Name

PPO, Blues, etc (from insurance card)

Policy Number

Policy Holder (Subscriber) Name

The policy holder may be you, a spouse, a parent or guardian

Policy Holder (Subscriber) Address

Policy Holder (Subscriber) City

Policy Holder (Subscriber) State

Policy Holder (Subscriber) Zip Code

Policy Holder Relationship to Client

Parent, Guardian, Spouse etc

Policy Holder Sex

Male Female

Policy Holder (Subscriber) Date of Birth

Group Number

Your information will be encrypted.

New Client Request for Services

Attention:

Attention:

GPS Guide to Personal Solutions