smhwi.com - PCP pre-registration Form

PCP pre-registration Form
NOTE : A photo ID must be uploaded with this form in order to process your registration. You may take a photo of your ID and other supporting documents, and upload as instructed below. If you have health insurance , please include photos of the front and back of the insurance card. You can upload these images utilizing this form or send them to PCAdmissions@smhwi.com once these steps are completed and the admissions representative will call you to schedule an appointment. When this form is completed an email will be sent to you with instructions on how to set up your patient portal and how to complete your intake forms. Thank you!
Patient Name:

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Sex ( assigned at Birth)

MaleFemale
Patient Address: We can only treat Patients with in Arizona
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name
Phone Number
Please enter a valid phone number.
Emergency Contact Relationship:
Please select a Payment Option:

Cash Pay ( No Insurance)Commercial InsuranceMilitary InsuranceMedicare Part A and BMedicare Part A and B with Supplemental Secondary Insurance
Who referred you or source of referral:
Treatment of provider(s)/service(s) needed:

Psychiatric Evaluation / Medication Management (with a NP/PA)Psychiatric Evaluation / Medication Management (With a MD) *availability may be limited*Therapy (With an L PC)Couples / Family Therapy (With an L PC)Intensive Outpatient programDUI CoursePrimary Care ProviderOther
Reason(s) for appointment/ additional information:
Upload Front and back of insurance card

Cancelof
Upload ID / Drivers license

Cancelof
**( patients using insurance will need to provide insurance cards prior to getting on the
schedule)*
Should be Empty: