Patient Registration Form - Existing Patients Lifespan Behavioral Health Services PC. Patient Registration FormName* First Middle Last Date of Birth* Month Day Year Gender*FemaleMaleTransgenderDeclinedMarital Status Single Married Divorced Widowed Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred Phone Number* Home Cell HomeCellEmail* Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown/Declined Race American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Island White Other Unknown/Declined Preferred Language English Preferred Communication for Appointment RemindersAppointment reminders are a courtesy service; all patients are responsible for remembering their scheduled appointments. We require a minimum of 24-hour notice for cancellations. Failure to do so may result in a charge for the missed appointment. Automated Text Automated Email Guarantor if not the patient (financially responsible party for minor or incapacitated adult)Guarantor Name First Last Date of Birth Month Day Year Relationship to Patient Address Street Address City State / Province / Region ZIP / Postal Code Guarantor Preferred Phone Number Home Cell HomeCellEmailNote: By providing a phone number or email address, you are consenting to being contacted at that number or address regarding your treatment or billing information. In addition, your email will be used to invite you to join our secure patient portal. Please upload your state issued ID card.Drivers License, Passport, Non-Drivers License Allowed file types include: jpg, png, pdf, gif, HEIC Maximum file size allowed: 25 MB If you are having a hard time uploading your ID card, please email a photo of it to intake@lsbhtherapy.com. Please include patient's name and DOB with Ins. card/photo ID. Thank you!Accepted file types: jpg, png, pdf, gif, heic, Max. file size: 25 MB.Please upload your insurance card.Allowed file types include: jpg, png, pdf, gif, HEIC Maximum file size allowed: 25 MB If you are having a hard time uploading your ID card, please email a photo of it to intake@lsbhtherapy.com. Please include patient's name and DOB with Ins. card/photo ID. Thank you!Accepted file types: jpg, png, pdf, gif, heic, Max. file size: 25 MB.Emergency Contact Information & Relationship to PatientName First Last Relationship Emergency Contact Phone*Insurance InformationPrimary Insurance Name* Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Policy ID #* Group/Plan #* Co-Pay $Subscriber Name* First Last Subscriber Date of Birth* Month Day Year Subscriber Employer* Secondary Insurance Name Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Policy ID # Group/Plan # Co-Pay $Subscriber Name First Last Subscriber Date of Birth Month Day Year Subscriber Employer Client SignatureDate Month Day Year Parent/Guardian SignatureFor minor First Last ConsentThe above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Lifespan Behavioral Health Services or my insurance company to release any information required to process my claims. I give my consent.NameThis field is for validation purposes and should be left unchanged. Δ
