Opening Doors by Nurturing Strengths

 

Jenna Saul, M.D.

  

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Intake form

 

Once you have scheduled an appointment at CAPC, please complete and submit this registration form. Please bring your insurance cards to the appointment.

CAPC, LLC Benefits and Managed Care Worksheet

 

PATIENT INFORMATION
Patient Name: Pt. Address:
   
D.O.B:  

City:State: Zip:

   
SSN:       Phone AM:   PM:   
   
Care Start Date:       Referral Source:
   
Presenting Problem:
 

PRIMARY INSURANCE INFORMATION
Insurance Company Name Please complete the information below if it is different from the patient’s:
   
 ID # Insured Name (If not Patient):   
   
Group #: Relationship to pt:
   
Effective Date: Insured D.O.B:    
   
Employer: SSN:  
   
Insurance Address: Insured Address:
   
City:   State: Zip: City: State:Zip:
   
Insurance Phone:   Insured Phone AM:   
   
Insurance Fax: Insured Phone PM:
   
In Network:  Y N Benefit Coverage:  
   
Out of Network:  Y N Benefit Coverage:  
   

Co-pay: $:

 
   

SECONDARY INSURANCE INFORMATION
 Insurance Company Name: Please complete the information below if it is different from the patient’s:
 ID #: Insured Name (If not Patient):    
   
Group #: Relationship to pt:
   
Effective Date: Insured D.O.B:    
   
Employer: SSN:  
   
Insurance Address: Insured Address:
   
City:   State: Zip: City: State: Zip:
Insurance Phone:   Insured Phone AM:   
   
Insured Fax: Insured Phone PM:
   
In Network:  Y N Benefit Coverage:  
   
Out of Network:  Y N Benefit Coverage:  
   

Co-pay: $:  

  
   
 Self-Pay?   Y N  
Doctor's Name:   Street:
   
Phone: City:  State: Zip:
Pharmacy Name:   Street:
   
Phone: City: State:Zip
Mail order Pharmacy Name:   Street:
Phone: City:  State: Zip:
   

 
HAVE YOU ALSO COMPLETE YOUR HEALTH HISTORY? If not, after you have submitted this form, Go back to the locations page to find it!  
 
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