Appointment Request

Step 1 - Patient Information

First Name
Last Name
Middle Initial
Maiden Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

 

Last Four of SS#
Date of Birth (Mo/Day/Year)
Sex	Male Female

Step 2 - Appointment Details

            Have you been seen at New Horizons before?  Yes No

Reason for appointment:

Step 3 - Requestor Information

            The person completing this form.

            I am submitting this appointment request for Myself Outside Physician Guardian My child My spouse My parent My patient and I am over 18 years of age.

            Please complete the following information if you are not completing this request for yourself.

            First Name:            Last Name:                   

Step 4 - Primary Health Insurance Information

            Does the patient have insurance? Yes No

            Person responsible for the patient's account?  Self Guardian Parent Other

            If you selected "Other", please explain:

              (Please provide insurance information as it appears on the insurance card.)

                Name of Insurance:  

                Policy #:    Group Name or #:

                Insurance Type:  HMO PPO POS EPO Medicaire Medicaid Other    Electronic Payor ID:

             If you selected "Other", please explain:        

             Effective Date:

             Mail Claims To (Name):     

             Mail Claims To (Address):

             Mail Claims to (City, State, Zip):

             Claims Contact Phone #:

Step 5 - Secondary Health Insurance Information

            Does the patient have secondary insurance?  Yes    No                    

Step 5 - Submit Request

            Click "Submit" below.  A representative will contact you shortly.