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/Child Health Plus MVP Monroe Plan Aetna Independent Health BC/BS of Rochester SS#: BC/BS of Western NY Medicaid other (please specify): Gender: Male Female Transgender Policy Number: Race: (check all that apply) American Indian or Alaska Native Asian Policy Holder's Name: or African American Hispanic Relationship to Client: Native Hawaiian or Pacific Islander White Secondary Insurance: Ethnicity: Excellus Family Health/Child Health Plus MVP Hispanic or Latino Monroe Plan Aetna Independent Health BC/BS of Rochester Not Hispanic or Latino BC/BS of Western NY Medicaid Decline other (please specify): Current grade: Policy Number: Policy Holder's Name: School District: Relationship to Client: Address: Responsible Party: (ONLY IF DIFFERENT THAN THE PATIENT) Name: Phone #: Address: Can we leave a message? Yes No Relationship to Client: Address: Parent/Guardian Contact Information: Referral Source Contact Information: Name: Name: Email Address: Email Address: Address: Address: Phone #:
Client Information: Client Name: DOB: SS#: Gender: Male Female Transgender Race: (check all that apply) American Indian or Alaska Native Asian or African American Hispanic Native Hawaiian or Pacific Islander White Ethnicity: Hispanic or Latino Not Hispanic or Latino Decline Current grade: School District: Address: Phone #: Can we leave a message? Yes No 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/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: 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: Relationship to Client: Parent/Guardian Contact Information: Name: Email Address: Address: Phone #: Referral Source Contact Information: Name: Email Address: Address:
2017-MH%20Clinic%20Referral%20Form.docx