New Patient Form – (319) 626-3300

Primary Email *

Please provide us with your primary email address.

Legal Name *

First

Middle

Last

Please provide us with the legal name of the patient

Aliases / Nickname

Please provide the short name or desired name/pronoun to be addressed by.

Date of Birth *

Please provide your Date of Birth

Patient's Social Security Number *

Please provide the Social security number of the patient.

Gender *

Please select your gender, if this is not applicable to you. Please select other.

Address *

Please provide the full address of the patient including the city state and zip code. EX: 320 West Cherry St, North Liberty Iowa, 52317

Primary Phone Number *

Please provide the primary phone number including the area code to contact the patient. EX: 319-626-3300

Alternate Phone Number

Please provide if applicable, a telephone number to reach the patient in the event we have been unable to reach them.

Marital Status *

Please select the applicable marital status.

Emergency Contact *

First

Last

Please provide the name of an emergency contact for us to reach in relation to urgent messages regarding the patient's care.

Emergency Contact Phone Number *

Please provide the phone number(s) including the area code of whom we should reach out to with urgent information.

Is the patient a minor? *

Please designate if the patient is a minor (Under 18 years of age at time of submitting this application)

Minor's Mother Contact Information

Please provide the contact information for the patients mother. Please include their name, address (including city, state, and zip code), phone number, and date of birth.

Minor's Father Contact Information

Please provide the contact information for the patients father. Please include their name, address (including city, state, and zip code), phone number, and date of birth.

Minor's Guardian Contact Information

Please provide the contact information for the patients legal guardian. Please include their name, address (including city, state, and zip code), phone number, and date of birth.

Primary Insurance *

Please provide the type of insurence the patience is covered by EX: Wellmark Blue Cross Blue Shield

Subscriber ID *

Please provide the insurance subscriber ID. This can be generally found on the front of the card, occasionally called "SubID or SID".

Group Number *

Please provide the group number for the insurance. Typically located beneath the subscriber ID

Insurance Provider Phone Number *

Please provide the the insurance provider phone number, can typically be found on the back of your insurance card under a section for Mental Health Services - Or Generalized Customer Service.

Patients Employer *

Please provide the patients employer, if the patient is not employed please state "Unemployed"

Subscriber Name *

First

Last

Please provide the name of name of the primary insurance carrier. (The person that is listed the policy owner, generally whomever is paying for the insurance policy)

Relationship to Patient *

If the insurance is under a spouse parent or other person, please provide their relationship to the patient EX "Father, Mother, Guardian, ect"

Subscriber Address *

Please provide the entire address (city, state and zip code) of the subscriber, if it is the same as the patient you may simply say "Same as patient"

Secondary Insurance

Secondary insurance is generally another policy that covers the patient for services that may not be covered by the primary insurance. Occasionally called "Supplement Insurance" Generally seen in minors or people over the age of 65+

Group Number

Subscriber Name

First

Last

Relationship to Patient

Subscriber Address

Employer

Guarantor Name *

First

Last

A guarantor is a financial term describing an individual who promises to pay a borrower's debt in the event that the borrower defaults on their loan obligation. Guarantors pledge their own assets as collateral against the loans. If the person responsible is the patient, you may type "Same as patient"

Guarantor's Social Security Number *

Please provide the Social security number of the Guarantor.

Guarantor's Relationships to Patient *

Please provide the relationship to the patient.

Guarantor Gender *

Please provide the patients gender.

Guarantor DOB *

Guarantor Address *

Please provide the entire address including city state and zip code. if the person responsible is the patient, you may type "Same as patient"

Guarantor Primary Phone Number *

Please provide the phone number for the guarantor

Guarantor Secondary Phone Number

Guarantor's Employer

Other Comments

In the event you have additional comments or questions, or wish to provide additional information or instruction or requests. Please do so here.

HIPPA *

I Agree

I acknowledge that I have received a copy of the Meadowlark Psychiatric Services HIPAA brochure located here: www.MeadowlarkPsych.com/hippa

I have reviewed Meadowlark Policies *

I Understand and Agree

https://meadowlarkpsych.com/policies/

Insurance Terms and Conditions *

I Understand and Agree *

I hereby authorize Meadowlark Psychiatric Services to furnish the insured’s insurance company information, which said insurance company, may request concerning my present circumstances. I further authorized Meadowlark Psychiatric Services to release diagnostic information relative to my treatment, to a laboratory or hospital of my choice, for billing purposes only. I hereby assign Meadowlark Psychiatric Services all money to which I am entitled for expenses relating to the services performed from time to time, but not to exceed my indebtedness to Meadowlark Psychiatric Services. It is understood that any money received from the above named insurance company over and above my indebtedness will be refunded to me when my bill is paid in full. I understand that I am financially responsible to Meadowlark Psychiatric Services for charges not covered by this assignment. I further authorize photocopies to be made of this authorization and assignment for attachment to any insurance form and authorize the insurance company to accept the photocopy. The authorization shall continue and be in force and effect until revoked in writing by me.

By selecting I understand and Agree", you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Meadowlark or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Meadowlark. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement.

Electronic Signature *

Date *