Getting Started

Welcome to Medens Health
Let's get started!

We'd like to learn more about what brings you to us. To help us better understand your goals and preferences, we'll ask you to:

- Share some basic information so we can contact you.

- Tell us more about the type of care you're seeking.

- Elect the method you intend to use to pay for your care.

This questionnaire will take about 5 minutes and you may use your mobile phone, tablet or computer. All of the information you disclose is protected by HIPAA and will remain confidental.

We make every effort to respond as soon as possible. However, if you contact us after-hours, over the weekend, or on a holiday, our follow-up may be delayed.

If you or someone you know is experiencing a life-threatening emergency or is in crisis, call 911 or go to the nearest emergency room. Click here for crisis resources that are available 24/7.

Appointment availability as of December 1, 2023

Medens Health complies with timely access to care legislation and we offer appointments for non-urgent routine care within 10 business days. However, for some of our locations, all of our providers are full and not accepting new patients. If you'd like, we can place you on a wait list and reach out when an opening becomes available.

Our availability as of December 1st is:

Arizona:
All providers are full and not accepting new patients at this time. The next available appointment is January 15. Only virtual appointments are offered.

California:
Counseling/therapy: We are accepting 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 mid-January.

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

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

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

Washington:
All providers are full and not accepting new patients at this time. The next available appointment is in January. 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 providers in Nevada are full and not accepting new patients.

If you'd like to be placed on the waitlist, please proceed. We look forward to welcoming you in mid January.
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 pay for services in cases where symptoms meet criteria for a qualifying mental health diagnosis, whether or not they cause significant suffering.

- Insurance companies often place restrictions on the type or amount of therapy that can be provided.

- Your health records are not private when going through insurance. If you choose to use your health insurance, you agree to allow claims adjustors to audit your complete record any time they want.

- In the event that congress or the courts repeal protections for patients with pre-existing conditions, your mental health diagnosis could be used as a pre-existing condition to deny payment for future services.
What’s your payment preference?*

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

We need your plan information to check your benefits. You'll also need to upload pictures of your insurance card and photo ID. When you have these cards in hand, click Next to continue.

Insurance Information
Medens Health is in network with many insurance plans. However, there are some exceptions. If we are not in network with your plan, you will pay us up front and we will provide you a SuperBill to submit to your insurance plan for reimbursement.

By disclosing your insurance information, you authorize us to verify your mental health eligibility and benefits, including any copay and/or deductible. Results are typically available in two business days.

Each provider has different circumstances when it comes to insurance. Some don’t accept insurance, some accept a few plans, and some accept many.

If you have specific questions regarding your mental health benefits, please contact your healh plan directly.
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 originally 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'd like to add regarding insurance, availability, preferences, or other general comments? To ensure your privacy, please limit your response to the topics listed. We will gather more information from you during the intake process.
How did you find us?*
Date*

MonthDayYear

MinutesAM/PM Option
Please sign.*

Clear
By submitting, you agree to our Privacy Policy.
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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!