Getting Started

Welcome to Medens Health
Let's get started!

We would like to learn more about what brings you to us. To help us better understand your goals and preferences, please:

- Share some basic information so we can contact you.
- Tell us more about the type of care you are seeking.
- Indicate the method you plan to use to cover the cost of your care.

This questionnaire will take approximately 5 minutes to complete, and you can use your mobile phone, tablet, or computer. All information you provide is protected by HIPAA and will remain confidential.

We strive to respond as quickly as possible. However, our follow-up may be delayed if you contact us after hours, on weekends, or during holidays.

If you or someone you know is experiencing a life-threatening emergency or is in crisis, please call 911 or go to the nearest emergency room.

Appointment availability as of November 11, 2024

Medens Health is committed to complying with timely access to care legislation by offering appointments for non-urgent routine care within 10 business days. However, at some of our locations, all providers are currently full and unable to accept new patients. If you would like, we can add your name to a waitlist and notify you when an opening becomes available.

Our availability as of November 11th is:

Arizona:
All providers are full and not accepting new patients at this time. The next available appointment is December 1st. Only virtual appointments are currently available.

California:
Counseling/therapy: We are offering new patient appointments within 10 business days. Most availability is for virtual appointments; in person is only available at our Beverly Hills and Orange County locations.
Psychological testing: We are accepting new patients with first appointment dates in late January.

Iowa:
We are accepting new patient appointments within 10 business days. Only virtual appointments are currently available.

Michigan:
All providers are full and not accepting new patients at this time. The next available appointment is in late December. Only virtual appointments are currently available.

Nevada:
Counseling/therapy: All providers are full and not accepting new patients at this time. The next available appointment is in mid-October.
Psychological testing: We are accepting new patients with first appointment dates in early January.

Washington:
All providers are full and not accepting new patients at this time. The next available appointment is in December. Only virtual appointments are offered.

If you are located in a state where we aren't able to offer you an appointment soon, we'd be happy to place you on the waitlist. Please note your waitlist preference in the comments section at the end of this questionnaire.

A little about you

Let's get started with some basic information.
Client (individual receiving care):*

First NameLast Name
Email:*
example@example.com
Mobile Number*
Please enter a valid phone number.
What’s the best way to reach you?*
What state do you reside in?*
Did you see the appointment availability disclaimer on page two?

Presently, all of our licensed providers in Nevada are full and not accepting new patients. Our Externs, who are student trainees, are accepting new patients who are Nevada Medicaid beneficiaries.
To proceed, please acknowledge the following:*

I have read the above disclaimer and want to be placed on the waitist. I understand it may be 2 months until I am offered an appointment.

Are you submitting this on behalf of someone else? For example, a minor or dependent adult.*

YesNo
What is your name and relationship to this individual?*
Ex. First name Last name, Parent

Paying for your care
Do you intend to use your health insurance or do you prefer to pay out of pocket?

If you want to use insurance, keep in mind:

- Insurance will only cover services if symptoms meet the criteria for a qualifying mental health diagnosis, regardless of whether those symptoms cause significant distress.

- Insurance companies often limit the type or amount of therapy that can be provided.

- Your health records are not confidential when using insurance. By choosing to use your health insurance, you are granting claims adjusters the right to audit your complete medical record at any time.

- It is important to understand that if Congress or the courts repeal protections for patients with pre-existing conditions, your mental health diagnosis could be classified as a pre-existing condition, potentially leading to denied coverage for future services. Being aware of this can help you plan and prepare for possible changes in your insurance coverage.
What’s your payment preference?*

Self-pay - I'll pay out of pocketI want to use insurance as my primary payment method

To verify your benefits, please provide your plan information. Additionally, you'll need to upload pictures of your insurance card and photo ID.

Once you have these cards ready, click Next to proceed.

Insurance Information
Medens Health is in-network with many insurance plans, but there are some exceptions. If we are not in-network with your plan, you will need to pay us upfront. We will then provide you with a SuperBill that you can submit to your insurance for reimbursement.

By sharing your insurance information, you authorize us to verify your mental health eligibility and benefits, including any copay and deductible. The results of this verification are typically available the next business day.

Each provider may handle insurance differently—some may not accept insurance at all, some accept only a few plans, and others accept many.

If you have specific questions about your mental health benefits, it is important to contact your health plan directly. They can provide you with the most accurate and up-to-date information.
Insurer:*
Mednes Health is contracted with these insurers only. If yours isn't listed, select 'Other' and provide further details in the Comments section on the next page. If your preferred provider is not contracted with your plan, we will inform you and present others who are In Network.
ID Number:*
Insurance card issue date:

MonthDayYear
If known
Date of Birth:*

MonthDayYear
Date
Upload a copy of your insurance card.*

Cancelof
Upload a copy of your license/ID card.*

Cancelof
Address on file with your insurance plan:*

Street Address

Street Address Line 2

CityState

Zip Code
Are you the primary subscriber on your insurance plan?*

YesNo
For insurance purposes, what sex is listed on your birth certificate?*

FemaleMaleDecline to answer
Do you receive your health insurance through Medicaid / Medi-Cal?*

YesNo
Since you're a Medicaid / Medi-Cal beneficiary, we need the number on your BIC (Benefits Identification Card), too. If you don't have the card handy, please enter your Social Security Number (SSN) so that we can accurately process your claim. *

Congrats, you're all done!
Is there anything else you would like to add about insurance, availability, preferences, or other general comments? To protect your privacy, please limit your response to the topics mentioned. We will collect more information from you during the intake process.
How did you find us?*
Date*

MonthDayYear

MinutesAM/PM Option
Please sign.*

Clear
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Welcome to Medens Health

A little about you

How would you prefer to receive care?

What is the main reason you are seeking care?

Paying for your care

Insurance Information

Congrats, you're all done!