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
Confidentiality Information
  1. Please list ALL the family members and/or ANY other persons, if any, whom we may inform about general medical condition and diagnosis” (including treatment, payment and healthcare). This might include anyone bringing a child to an office visit or making an appointment.
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  4. Please list the family members or significant others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY.
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  7. Please provide the address of where you would like postcards and/or correspondence from our office to be sent if other than your home.
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  9. Please indicate if you want all correspondence from our office sent in a sealed envelope marked “CONFIDENTIAL”
  10. Marked Confidential
  11. Please provide the telephone number, if any, where you want to receive calls about your appointments, or other health care information, if other than your home phone number. * I am fully aware that a cell phone is not a secure and private line.
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  13. Please provide an e-mail address that we may use in confirming your next appointments.
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  15. May confidential messages (i.e. Appointment Reminders) be left on your home telephone answering machine or voicemail?
  16. Messages Left At Home
  17. May confidential messages (i.e. appointment reminders) be left on your office telephone answering machine or voicemail?
  18. Messages Left At Office
  19. To whom may we speak to about payment of your account?
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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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