Birchwood Healing Place
Link to telehealth
Please note this form must be filled out in its entirety even if the answer is N/A, none, or no, Otherwise it will not allow you to submit the form. Once the form has been received someone from this office will reach out to you.
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Date of Birth
May we contact by;
Please check all that apply.
Method of payment
Humana Caresource KY marketplace
United Health Medicaid
Phone number of back of card
We encourage you to contact member services with your insurance company prior to your first appointment and inquire about deductible, co-payment and or coinsurance for CPT code 90837. In the meantime put N/A if you do not know this information. All KY medicaid plans are 0.00 copay at this time.
Primary insured name, if you are on someone else's policy
Primary Insured date of birth , if you are on someone else's policy
Can you described in a few sentances or less why you are seeking care at this time?
Are you involved in an open DCBS/ CPS case?
CPS stands for Child Protective Services.
Are you involved an ongoing custodial dispute at this time?
Are you involved in an open / pending SSI case?
How did you hear about Birchwood Healing Place
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