MARC OTP Application
Name
First Name
Last Name
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Insurance
Medicare
Self-Pay
Medicaid
Member #
Do you have a Primary Care Physician?
Yes
No
Who is your PCP?
Name
PCP Phone Number
-
Area Code
Phone Number
Are you currently pregnant?
Yes
No
List all CURRENT medications
*
Are you currently taking Methadone
Yes
No
If yes, please list prescribing doctor
How long have you been taking it?
Are you currently employed?
Yes
No
Who referred you to our program? / How did you hear about us?
Substance Use History
*
Are you currently in residential treatment?
Yes
No
Where?
For how long?
Are you currently on probation?
Yes
No
Parole Officer's Name
Submit
Should be Empty: