Client Information: Insurance: All Insurance Information must be completed and a copy of insurance cards must be provided. (Self-pay with a sliding Client Name: scale is available) Primary Insurance: DOB: Excellus Family Health Plus MVP Monroe Plan Independent Health BC/BS of Rochester SS#: BC/BS of Western NY Medicaid other (please specify): What pronoun do you use? ( ex:He, She , They):_____________ Policy Number: Gender: Male Female Transgender Policy Holder's Name: Race: (check all that apply) Relationship to Client: American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Pacific Islander White Secondary Insurance: Excellus Family Health/Child Health Plus MVP Monroe Plan Aetna Independent Health BC/BS of Rochester Ethnicity: BC/BS of Western NY Medicaid Hispanic or Latino other (please specify): Not Hispanic or Latino Decline Policy Number: Policy Holder's Name: Current grade: Relationship to Client: School District: Responsible Party: (ONLY IF DIFFERENT THAN THE PATIENT) Address: Name: Address: family members in the Home: Phone: Relationship to Client: ___________________________________________________ Phone #: Can we leave a message? Yes No Email Address:
Client Information: Client Name: DOB: SS#: What pronoun do you use? ( ex:He, She , They):_____________ Gender: Male Female Transgender Race: (check all that apply) American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Pacific Islander White Ethnicity: Hispanic or Latino Not Hispanic or Latino Decline Current grade: School District: Address: family members in the Home: ___________________________________________________ Phone #: Can we leave a message? Yes No Email Address: Insurance: All Insurance Information must be completed and a copy of insurance cards must be provided. (Self-pay with a sliding scale is available) Primary Insurance: Excellus Family Health Plus MVP Monroe Plan Independent Health BC/BS of Rochester BC/BS of Western NY Medicaid other (please specify): Policy Number: Policy Holder's Name: Relationship to Client: Secondary Insurance: Excellus Family Health/Child Health Plus MVP Monroe Plan Aetna Independent Health BC/BS of Rochester BC/BS of Western NY Medicaid other (please specify): Policy Number: Policy Holder's Name: Relationship to Client: Responsible Party: (ONLY IF DIFFERENT THAN THE PATIENT) Name: Address: Phone: Relationship to Client:
updated%20Behavioral%20health%20Referral%20Form-WTP-8-17-18.docx