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In order to streamline the new patient registration process, we are pleased to offer you the option of pre-submitting your demographical and insurance information via this secure and encrypted page. Once RCBM staff receives your submission, we will promptly call and verify your insurance benefits. Knowing your benefits will help us to determine the RCBM providers that you are able to see. Once we have this information, Ann, our office manager and new patient registration specialist, will call you to talk to you about your presenting issues and help you schedule an appointment. Thank you.
This form will encrypt your information. Please feel confident that your information will be retrieved securely.
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Please click here If You Will Not Be Using Insurance
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Today's Date
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* First Name
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Middle Initial |
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* Last Name
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* Patient's Date of Birth
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Social Security Number
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Presenting Concern(s)
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* Primary Phone Number
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Best Time to Call |
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(please also indicate type of phone number)
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Secondary Phone Number
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Best Time to Call |
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(please also indicate type of phone number)
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* Number to be used by RCBM for reminder calls and other correspondence
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* I authorize RCBM to leave messages at the correspondence number indicated above
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(Please enter initials) |
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* Street Address
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* City
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* State
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* Zip Code
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* Email Address
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* Email Address Confirmation
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| Is there a specific provider you are requesting to see? |
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PRIMARY INSURANCE
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* Do You Have Medicare?
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> Yes No |
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* Do You Have Medicaid?
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> Yes No |
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* Type of Primary Insurance
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* Name On Insurance Card
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Responsible Party (Cardholder)
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* Relationship to Party
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Employer of Responsible Party
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Hourly Salary |
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SSN of Responsible Party:
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Birth Date of Responsible Party:
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Contract Number
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Group Number
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Customer Service Number
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Mental Health Number
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| Has the patient been seen by any other Mental Health Provider in this calendar year? Yes No |
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If Yes, how many times?
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SECONDARY INSURANCE
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Type of Primary Insurance
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Name On Insurance Card
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Responsible Party (Cardholder)
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Relationship to Party
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Employer of Responsible Party
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Hourly Salary |
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SSN of Responsible Party:
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Birth Date of Responsible Party:
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Contract Number
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Group Number
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Customer Service Number
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Mental Health Number
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How did you hear about us?
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Internet Search Insurance Referral Family Member Friend
Referred by another Professional Other
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If you chose Other above, please be specific.
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We will attempt, to the best of our ability, to verify your mental health benefits with your insurance company and pair you with the appropriate provider. Ultimately, however, any accrued balance is the responsibility of the patient or the patient’s parent/guardian. Thank you.
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