Appalachian Wellness New Patient ID 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 $500 for missed 4 hour appt's, this includes calling within 24 hours of your appointment to cancel. Having all information below helps us deal with any “Prior Authorization” requirements by any type of health coverage that you have.Thank you for choosing Appalachian Wellness!
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First Name *
Middle Name
Last Name *
Preferred Name *
Date of Birth *
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Gender *
Social Security Number
Cell Phone Number *
Personal EMail Address
Home Phone Number
Work Phone Number
Preferred Means of Communication
Clear selection
Home Address 1 *
Home Address 2
Home Address City *
Home Address State *
Home Address Zip Code *
1. Primary Insurance Carrier Name & Type; *
(Medicare, Medicaid, Commercial Insurance Company, Self, Workman's Compensation; HMO, PPO, etc.)
1. Primary Insurance Plan ID Number;
1. Primary Insurance Plan Group Number;
Date Effective FROM;
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Date Effective TO;
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Co-Pay Type
Clear selection
Co-Pay Amount ($)
2. Secondary Insurance Carrier Name & Type
(Medicare, Medicaid, Commercial Insurance Company, Self, Workman's Compensation; HMO, PPO, etc.)
2. Secondary Insurance Carrier ID #;
2. Secondary Insurance Carrier Group ID #;
Date Effective FROM;
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Date Effective TO;
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Co-Pay Type;
Clear selection
Co-Pay Amount ($);
3. Tertiary Insurance Carrier Name & Type;
(Medicare, Medicaid, Commercial Insurance Company, Self, Workman's Compensation; HMO, PPO, etc.)
3. Tertiary Insurance Carrier ID#;
3. Tertiary Insurance Carrier Group#;
Date Effective FROM;
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Date Effective TO;
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Co-Pay Type;
Clear selection
Co-Pay Amount ($);
Relationship to Guarantor
Clear selection
Guarantor First Name *
Guarantor Middle Name *
Guarantor Last Name *
Guarantor DOB *
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Guarantor Social Security Number *
Guarantor EMail Address
Guarantor Best Phone #
Guarantor Home Address 1
Guarantor Home Address 2
Guarantor City
Guarantor State
Guarantor Zip Code
Ethnicity/Race *
Preferred Language *
Employer Business Name
Work EMail Address
Next of Kin First name
Next of Kin Middle Name
Next of Kin Last Name
Relationship to Next of Kin
Next of Kin Phone #
Next of Kin EMail Address
Next of Kin Address 1
Next of Kin Address 2
Next of Kin City
Next of Kin State
Next of Kin Zip Code
Patient's Mothers Maiden Name
Preferred Pharmacy (Name, Address, Phone) *
Reason for seeking care at Appalachian Wellness *
If you chose "other", why did you schedule an appointment with us?
How did you find out about our practice (please tell us which/who) Billboard, Bus sign, Email, Church/Pastor, Counselor/Therapist/Psychology group/IOP group, Patient of Appalachian Wellness (name?), Sober house, which Website or Web Search Engine (Eg. Google, Yelp) did you use to find us?
Name of Primary Care Provider (PCP)
Primary Care is an extremely important specialty, your PCP is responsible for knowing what is going on with you so that your care can be coordinated if necessary between other providers. We believe it's VERY important to keep your PCP aware of what we're doing to help you and routinely send PCP's a summary letter after your initial appointment with us and periodically as needed or requested by you.
Primary Care Provider Fax Number
Are code # Number; Eg. 828 785 1802
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