First Contact

EMERGENCY ASSISTANCE

If you need emergency assistance, please call 911 or go to the closest ER.

LET'S GET STARTED!

1. What's you appointment preference?

When would you like to schedule your appointment?

I prefer mornings.

I prefer afternoons.

I prefer the lunch hour.

We send text reminders for appointments. Please select your preference:

5 days before my appointment

2 days before my appointment

Both the 2 and 5 day notice

No text reminders

Did someone refer you or self-referral?

Anything else you'd like us to know about your schedule request?

2. Ok, let's get your information.

First Name

Middle Initial

Last Name

Complete Date of Birth (Month/Day/Year)

Gender

*Complete Street Address

City

State

Zip

Email (double check, please)

Cell Phone

May we email/text and call you at this number?

Yes

3. Please provide us with your ID # on insurance card: (Example: YQN286281007). Not all providers accept insurance, we will contact you discuss your options.

Insurance Plans Accepted: (non-expansion plans only)

BCBS ND

BCBS MN

BCBS PPO

SANFORD

Are you the primary policy holder? (Is the primary a spouse, parent or other?)

I am primary.

I am not the primary policy holder.

* Not all providers accept insurance. We will help to select the best match for you! We do not accept expansion plans or medical assistance.

4. How would you like to finish the intake process?

Would you like to continue the intake process online or would you prefer an email or call?

I'd like to finish my paperwork online using encrypted, HIPAA-compliant forms.

I don't feel comfortable with online forms, please email me the remaining paperwork as an attachment.

Please call me to discuss. I'd like to speak with a real person.

Great! We'll review your request and get back to you within 24-48 hours. Need to reach us sooner? Please call 701.478.7199.

Lastly, can I get your consent to send this form? By clicking yes, below, you are consenting to the use of digital communication.

Yes, I consent.

Your message will be encrypted and can only be read by Maddie.

Maddie

Intake Master

HI! My name is Maddie. I'll make sure your intake process goes well. You'll start with this form. Then, based on your comfort level, we can complete the entire intake process using HIPAA-compliant digital forms, or I can call you to complete the intake process. You have options. Select the right one for you. ________________________________ Privacy is everything to us. Hushmail is a recognized company and is HIPAA compliant. This means it offers the highest level of security for online communication and monitors security closely.

701-478-7199