Psychiatric Medication Management Interest Form
This form is intended to collect information regarding interest in meeting with our treatment team for psychiatric medication to facilitate scheduling. It is not intended to schedule appointments itself, or otherwise treat a psychiatric condition.
Incomplete forms might result in a delay of scheduling.
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By completing the form below, I agree to be contacted by an employee of Megen Rhine Consulting to schedule a medication management appointment once a schedule is created. Estimated first contacts to be no earlier than the 15th of December *
Name of Patient: *
Age of Patient:
Your Name: 
If completing for a minor
Best Phone Number:
Best Email Address:
Insurance:
Please check insurance according to billing responsibility: If Aetna is primary, check the primary column. If you only have coverage by one insurance, please only complete Primary Column
Primary
Secondary
Tertiary
Aetna
BCBS
Cigna
Medicaid
Medicare
United Healthcare
Optum
Community Care
Uninsured
Other
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