Patient Application – Adult

Hello and Welcome!

Please take a moment to review and fill out the new patient application form below. Submitting this form prior to your first appointment will ensure your prompt attention upon arriving. Our goal is to provide you and your family with excellent medical treatment along with our friendly, courteous service. Thank you again for choosing our physician associates, for specialized and exceptional ADD/ADHD healthcare!

Contact Information
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  8. (valid email required)
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Vitals Information
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Employer Information
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Insurance Provider
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  2. If “Yes” is selected all information below is required
  3. If you have secondary insurance complete the fields below
You Were Referred By
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Release Information
  1. By submitting this information, I, the above applicant, certify that I (or my dependent) have insurance coverage with the above selected insurance company. I assign directly to The ADD/ADHD Diagnostic & Treatment Center, PA all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorized the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this submitted data on all insurance submissions.
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