01 Patient Information Form (IOP Admit Packet)

Patient Information Form
Patient's Full Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Marital Status (please check most recent)*

MarriedDivorcedSingleWidowedLegally Separated
Social Security Number
Driver License

NumberState
Employer's Name
Occupation
Employer's Phone Number

Area CodePhone Number
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Spouse, Parent or Legal Guardian

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
Preferred Language*
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Pharmacy

Preferred PharmacyCityPhone
Primary Care Physician

Primary Care PhysicianCityPhone
Referring Physician

Referring PhysicianCityPhone
I heard about Beautiful Minds Medical from:

Website / FacebookReferred by Medical ProfessionalReferred by Friend / RelativeOther
Consent for Treatment, Billing and Release of Medical Information
I understand I am responsible for all charges incurred for professional medical/mental health services provided for me or my dependent, regardless of insurance coverage. I authorize direct payment of any benefits to Beautiful Minds Medical, Inc. from my insurance company, health plan, third-party payor on any intermediaries.

I authorize Beautiful Minds Medical, Inc. and Daniel L. Binus, MD, to release medical records and/or information to representatives of my insurance company/ health plan/third- party payor or any intermediary for the purpose of processing my medical/mental health claims or obtaining benefits. In addition, I authorize Beautiful Minds Medical, Inc. and Daniel L. Binus, MD, Inc. to release medical information to other providers for the purpose of specialist referrals and/or other continuing care.
I consent to treatment by Beautiful Minds Medical, Inc. for counseling, psychotherapy and/or psychiatric medical care as deemed advisable and/or necessary by the professional staff of Beautiful Minds Medical, Inc.I also consent the release of my medication history from my insurance company or pharmacy benefits manager to Beautiful Minds Medical, Inc.FOR MINOR CHILDREN PATIENTS: I also consent the release of my medication history from my insurance company or pharmacy benefits manager to Beautiful Minds Medical, Inc.
Patient's, Parent or Guardian's Signature*

Clear
Insurance Information
Subscriber's Full Name

First NameMiddle InitialLast Name
Subscriber's ID Number
Subscriber's Date of Birth

MonthDayYear
Date
Primary Insurance Company's Name
Insurance Company Phone

Area CodePhone Number
Coverage Effective Date

MonthDayYear
Date
Group Number
Policy Number
Secondary Insurance Subscriber's Full Name

First NameMiddle InitialLast Name
Secondary Subscriber's ID Number
Secondary Subscriber's Date of Birth

MonthDayYear
Date
Secondary Insurance Company's Name
Secondary Insurance Company Phone

Area CodePhone Number
Should be Empty:

Patient Information Form

Consent for Treatment, Billing and Release of Medical Information

Insurance Information