Intake Information - Insurance - For New and Established/Returning Patients

Please Note

Even if you recently saw Matt Sharpe, NPP at Linden Oaks, the following information is still essential and must be submitted before an appointment can be made.

PATIENT INFORMATION

First Name

Last Name

Middle Initial

Date of Birth

Age

Gender

Race

SS#

Street Address

City

State

Zip Code

Cell Phone Number

Home Phone

Is condition related to employment or accident?

Yes

Employer

Number of Children in Household

Marital Status

Sources of Income

Insurance Subscriber's Information

My Insurance Coverage is:

My own/ I am the primary insured person

Insurance is through my spouse

I have Insurance from my parents

Other

If insured is "Other" please explain

The following section is only for those who are not the person who is the primary insured. DO NOT LEAVE THIS BLANK unless the patient is the person is the primary insured person

First Name

Last Name

Middle Initial

DOB

Race

Gender

Street Address

City

State

Zip

Social Security #

Employer

INSURANCE INFORMATION

If selecting "Other" for Insurance company please explain

Contract #

Do you have secondary insurance? If so enter below:

Primary Care Doctor/Provider

(write "None" if appropriate)

Therapist

(write "None" if appropriate)

Enter any other pertinent information you would like to share with the office manager or the provider

Your Email Address

Please upload a copy of your drivers license and both sides of your insurance card

Add file

Please upload a file

Thank you for taking the time to complete this form. It will very much help the process of continuing care at the new location.

Your information will be encrypted.