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. Although we do not accept private insurance, we will provide you with forms to submit to your insurer so that you will be reimbursed directly by them per your insurance policy. Having this information will help 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 *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Preferred Name *
Your answer
Date of Birth *
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Gender *
Social Security Number
Your answer
Cell Phone Number *
Your answer
Personal EMail Address
Your answer
Home Phone Number
Your answer
Work Phone Number
Your answer
Preferred Means of Communication
Home Address 1 *
Your answer
Home Address 2
Your answer
Home Address City *
Your answer
Home Address State *
Your answer
Home Address Zip Code *
Your answer
1. Primary Insurance Carrier Name & Type; *
(Medicare, Medicaid, Commercial Insurance Company, Self, Workman's Compensation; HMO, PPO, etc.)
Your answer
1. Primary Insurance Plan ID Number;
Your answer
1. Primary Insurance Plan Group Number;
Your answer
Date Effective FROM;
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Date Effective TO;
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Co-Pay Type
Co-Pay Amount ($)
Your answer
2. Secondary Insurance Carrier Name & Type
(Medicare, Medicaid, Commercial Insurance Company, Self, Workman's Compensation; HMO, PPO, etc.)
Your answer
2. Secondary Insurance Carrier ID #;
Your answer
2. Secondary Insurance Carrier Group ID #;
Your answer
Date Effective FROM;
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YYYY
Date Effective TO;
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Co-Pay Type;
Co-Pay Amount ($);
Your answer
3. Tertiary Insurance Carrier Name & Type;
(Medicare, Medicaid, Commercial Insurance Company, Self, Workman's Compensation; HMO, PPO, etc.)
Your answer
3. Tertiary Insurance Carrier ID#;
Your answer
3. Tertiary Insurance Carrier Group#;
Your answer
Date Effective FROM;
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Date Effective TO;
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Co-Pay Type;
Co-Pay Amount ($);
Your answer
Relationship to Guarantor
Guarantor First Name *
Your answer
Guarantor Middle Name *
Your answer
Guarantor Last Name *
Your answer
Guarantor DOB *
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Guarantor Social Security Number *
Your answer
Guarantor EMail Address
Your answer
Guarantor Best Phone #
Your answer
Guarantor Home Address 1
Your answer
Guarantor Home Address 2
Your answer
Guarantor City
Your answer
Guarantor State
Your answer
Guarantor Zip Code
Your answer
Ethnicity/Race *
Preferred Language *
Employer Business Name
Your answer
Work EMail Address
Your answer
Next of Kin First name
Your answer
Next of Kin Middle Name
Your answer
Next of Kin Last Name
Your answer
Relationship to Next of Kin
Next of Kin Phone #
Your answer
Next of Kin EMail Address
Your answer
Next of Kin Address 1
Your answer
Next of Kin Address 2
Your answer
Next of Kin City
Your answer
Next of Kin State
Your answer
Next of Kin Zip Code
Your answer
Patient's Mothers Maiden Name
Your answer
Preferred Pharmacy (Name, Address, Phone) *
Your answer
Reason for seeking care at Appalachian Wellness *
If you chose "other", why did you schedule an appointment with us?
Your answer
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?
Your answer
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