BHA register logo

Welcome to the registration page for the Behavioral Health Associates Clinic. We hope you will find this page easy to use. Complete the form below and then simply click on the "submit" button at the bottom. Once we have received the information you will be contacted by our office to schedule an appointment. Having this information prior to your appointment will help to reduce unnecessary waiting and speed your visit with our staff. Thank you for your help.

 

Personal Information

Last Name       First Name:  

SexMale Female    Age

Date of Birth Address

City State Zip Code

Home Phone Work Phone

Email:

Occupation


Name of Nearest Relative Not Living with You

Address City

State Zip Code

Phone 


Who Referred You to This Office

Do You have a Primary Care Physician (Give Name)

May we communicate with your Physician?Yes No 

Reason for Coming to Dr. Carr


Billing Information

Insured/Responsible Party Name

Address City

State Zip Code

Home Phone Work Phone

Date of Birth


Insurance Information: Please take out your insurance card and look on the front and back
for the following information

Insurance Company Group Number/Name

Policy # Name of Insured

Insured's Date of Birth

Relationship of referred person to Insured

On the card will usually be found a telephone number to call for pre-authorization. If you find
that number please enter it below:


CONFIDENTIALITY NOTICE: Please note that email is not a secure form of electronic communication. This e-mail is covered by the Electronic Communication Privacy Act, 18 U.S.C. Section 2510-2521 and is legally privileged. The information contained herein is confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, or if an attachment is made in error, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this transmission in error, please notify the above person by telephone immediately by return e-mail and delete/trash the original message from your system. Thank you for your compliance.

 

 

 

 

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