Birchwood Healing Place
Home
About
Loretta
Madeleine
Payment and Fees
Link to telehealth
Contact
Blog
Birchwood Healing Place
Please fill out this form and an appointment will be scheduled.
Intake form.
Please note all this form must bill fill out in its entirety even if the answer is none, no, or N/A. Otherwise it will not allow you to submit the form.
*
Indicates required field
First name
*
Last name
*
May we contact by;
*
Mail
Email
Phone
Message
Text
Please check all that apply.
Method of payment
*
Cash
Credit Card
Insurance
Insurance Type
*
Aetna
Anthem Commerical
Anthem Medicaid
Cigna
None
Passport Medicaid
Wellcare Medicaid
Humana Medicaid
Humana Commercial
Policy Number/ Medicaid Number
*
Phone number of back of card
*
Co-Pay Amount
*
Primary insured name, if you are on someone else's policy
*
Primary Insured date of birth , if you are on someone else's policy
*
Name of Employer
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Emergency Contacts Relation to you
*
Do you have an open DCBS case?
*
Do you have an open custodial case?
*
Do you have an open / pending SSI claim?
*
How did you hear about Birchwood Healing Place
*
Submit