New Patient Enrollment

1Enrollment

2Patient Information

3Insurance

4Lifestyle

5Substance Intake

6Additional Information

Lighthouse Location*

GILBERT OFFICE: 4001 E Baseline Rd, Gilbert AZ 85234

SCOTTSDALE OFFICE: 15300 N 90th St, Suite 750, Scottsdale AZ 85260

Form Completed By:

Patient

Referral

[NEW PATIENT ENROLLMENT] Referred by:*

Patient Full Name*

First Last

Date of Birth (MM-DD-YYYY)*

MM slash DD slash YYYY

Gender

Email Address*

Phone Number*

Current Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Consent*

PLEASE CONFIRM (by checking box). LIGHTHOUSE PSYCHIATRY BRAIN HEALTH CENTER providers: DO NOT provide any forensic psychiatry/therapy mandated by court order, state professional licensing boards, or any evaluations will be used as material items for future court or board hearings.

Yes. I acknowledge, understand and accept statement.*

Consent*

PLEASE CONFIRM (by checking box). I am financially responsible for all fees, including insurance deductibles/copays/co-insurance, insurance non-covered services, drug screening, no show/late cancellation, and any accrued balance from services rendered. My credit/debit card information will be securely stored on fine.

Yes. I acknowledge, understand and accept statement.*

PLEASE select PAYMENT option(s) [select all that applies]

SELF-PAY (No insurance)

MEDICARE

MEDICAID (AHCCCS)

TRICARE

TRIWEST (CCN) (VA)

AETNA

UNITED (UBH, UMR, OPTUM, UHC)

BCBS

CIGNA

ACN

AMBETTER

COMPSYCH

HUMANA

MAGELLAN

Other

Other PAYMENT options

Subscriber Name

First Last

Subscriber Date of Birth

MM slash DD slash YYYY

Subscriber Relationship

Self

Spouse Partner

Parent/Guardian

Patient is a MINOR (<18 years old)? (BEWARE: If parents are DIVORCED or GUARDIAN, please upload any legal custody documents below)*

NO, I am an adult.

YES, minor has MARRIED parents.

YES, minor has DIVORCED parents with JOINT CUSTODY. (upload court documents)

YES, minor has DIVORCED parent with SOLE CUSTODY. (upload court documents)

YES, minor has GUARDIAN parents.

Patient has ACTIVE or PENDING legal case?*

YES

Reason(s) for Appointment (select ALL that applies)*

Medication Treatment

Counseling

TMS/MeRT

Spravato

Ketamine

Talk Therapy

OTHER (comment below)

Others (Explain)*

Substance Use Disorder

YES

List any substance(s) used without prescription.*

[Required] (Please provide brief description of your needs)*

This field is hidden when viewing the form

Upload File

Accepted file types: jpg, png, pdf, doc, Max. file size: 128 MB.

Upload the following: (1) insurance card (FRONT & BACK), (2) photo ID (FRONT & BACK), (3) court custody documents, and (4) any other supporting materials (30MB file size limit)

File Upload*

Drop files here or

Accepted file types: jpg, gif, png, pdf, docx, txt, Max. file size: 1 GB, Max. files: 10.

Upload the following: (1) insurance card (FRONT & BACK), (2) photo ID (FRONT & BACK), (3) court custody documents, and (4) any other supporting materials (30MB file size limit)

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New Patient Enrollment

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