Patient Registration Form - New Patients

Lifespan Behavioral Health Services PC.

Patient Registration Form

Name*

First Middle Last

Date of Birth*

MM

DD

YYYY

Services Requested*

Gender*

Marital Status

Single
Married
Divorced
Widowed

Address*

Street Address City State ZIP Code

Preferred Phone Number*

Home
Cell

Home

Cell

Email*

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Unknown/Declined

Race

Preferred Language

English

Preferred Communication for Appointment Reminders

Appointment 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

MM

DD

YYYY

Relationship to Patient

Address

Street Address City State / Province / Region ZIP / Postal Code

Guarantor Preferred Phone Number

Home
Cell

Home

Cell

Email

Note: 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!

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!

Emergency Contact Information & Relationship to Patient

Name

First Last

Relationship

Emergency Contact Phone*

Insurance Information

Primary Insurance Name*

Address

Street Address Address Line 2 City State Zip Code

Policy ID #*

Group/Plan #*

Co-Pay $

Subscriber Name*

First Last

Subscriber Date of Birth*

MM

DD

YYYY

Subscriber Employer*

Secondary Insurance Name

Address

Street Address Address Line 2 City State Zip Code

Policy ID #

Group/Plan #

Co-Pay $

Subscriber Name

First Last

Subscriber Date of Birth

MM

DD

YYYY

Subscriber Employer

Client Signature

Date

MM

DD

YYYY

Parent/Guardian Signature

For minor

First Last

Consent

The 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.

Name

This field is for validation purposes and should be left unchanged.