À la carte Established Patient Interval History Form
Email address *
Date of Completion of Patient ID Form *
Please Review & Complete this & all other forms. The documents at the bottom of this form require your signature.They will need to be printed out and signed by you. Please bring any insurance card(s)/information to your initial appointment and a government-issued photo ID such as a Driver's License. We are participating providers with BCBS, Humana, Medicare, Medicaid for NC & SC. We will bill private insurance carriers as a non-participating provider for other plans. There is a $150 fee for missed 1 hour appt's and $500 for missed 4 hour appt's, this includes calling within 24 hours of your appointment to cancel. Having all information below helps us deal with any “Prior Authorization” requirements by any type of health coverage that you have.Thank you for choosing Appalachian Wellness!
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First Name *
Middle Name *
Last Name *
Cell Phone Number *
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