Request Appointment Full Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Insurance Card*Please upload pictures of the front and back of your insurance card Drop files here or Accepted file types: jpg, png. Referral source:Online/WebsiteInsuranceList of Accepted Insurances: 1199 Aetna Blue Cross Blue Shield Cigna Medicare Oxford United Behavioral Health United HealthcareInsurance Name*Member ID:*Did you meet your yearly deductible?: *Choose oneYesNoHow much is your yearly deductible?:*How much is your copay?*Disclaimer: In the event your insurance does not cover the cost of the appointment, the patient is responsibleReason for Consultation: *Current SymptomsDuration of SymptomsCurrent Medications, if anyPlease check if you have any of these diagnoses: schizophrenia bipolar disorder substance abuse recent hospitalization any ongoing psychiatric disability Please check service(s) you are interested in: Medication Management Psychiatry TMS Neuromodulation Sleep Medicine Esketamine Treatment Mind-Body Wellness Preferred Time of Consultation:Urgent1-3 weeks4+ weeksSubmission of this form does not guarantee an appointment nor the coverage of said appointment given your insurance policy* I understand
