RBH New Patient Registration Form

RBH New Patient Registration

Please fill in the form below
Date of Intake Appointment:

MonthDayYear
Date
Patient Information:
Patient Name*

PrefixFirst NameLast NameSuffix
Parent/Legal Guardian Name (If patient is Minor or has a Legal Guardian)

PrefixFirst NameLast NameSuffix
Patient Date of Birth (DOB):*

MonthDayYear
Date
Please take a photo of the patient
Patient Gender:
Patient Marital Status
Contact Information:
Mobile/Cell Phone:

Area CodePhone Number
Home Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
E-mail :
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please let us know how we may contact you: (check all that apply):

Home PhoneMobile/Cell PhoneWork PhoneE-MailMail
Emergency Contact Information:
In case of emergency, please let us know who to contact...
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Area CodePhone Number
Health Insurance Information:
Primary Health Insurance
Primary Health Insurance:
If You selected "Other", please specify:
Primary Insurance Type
Primary -Insured/Subscriber Name:
Primary -Insured/Subscriber Date of Birth (DOB):

MonthDayYear
Date
Primary Insured/Subscriber SSN:
Primary -Employer:
Primary -Group #:
Primary -Policy #/Member ID#:
TRICARE BENEFITS ID # [9-11 characters]
Primary -Relation of Patient to Insured/ Subscriber
Primary -Provider 800 # on back of Health Insurance Card

Area CodePhone Number
Primary -Claims Address on Back of Health Insurance Card
Secondary Health Insurance
Secondary Health Insurance:
Secondary -If You selected "Other", please specify:
Secondary Insurance Type
Secondary- Insured/Subscriber Name:
Secondary -Insured/Subscriber Date of Birth (DOB):

MonthDayYear
Date
Secondary -Employer:
Secondary- Group #:
Secondary - Policy #:
Secondary- Relation of Patient to Insured/ Subscriber
Secondary -Provider 800 # on back of Health Insurance Card

Area CodePhone Number
Secondary - Claims Address on Back of Health Insurance Card
EAP Benefits
Does your Employer offer EAP Benefits:
If Yes, Please Enter EAP Authorization Number:
# of EAP visits Authorized:
EAP Provider Phone:

Area CodePhone Number
Please note that EAP is a short term counseling benefit. This does not cover Diagnostic Assessment/Intake or Psychological testing appointments.
Should be Empty:

RBH New Patient Registration

Patient Information:

Contact Information:

Emergency Contact Information:

Health Insurance Information:

Primary Health Insurance

Secondary Health Insurance

EAP Benefits