Oasis Registration Form
Oasis Registration Form
Patient Registration Form
Name
Name
*
First
Last
Date
Date
/
MM
/
DD
YYYY
Marital Status:
*
M
S
D
W
Home Phone:
Home Phone:
-
###
-
###
####
Work Phone:
Work Phone:
-
###
-
###
####
Cell Phone:
Cell Phone:
*
-
###
-
###
####
Address
Address
Street Address
Address Line 2
City
Select a State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State / Province / Region
Postal / Zip Code
United States
Country
Email:
*
Date of Birth:
Date of Birth:
*
/
MM
/
DD
YYYY
Is it ok to Text?
Yes
No
Is it ok to Email you?
Yes
No
Current Employer:
Occupation:
Primary Care Provider:
Primary Care Provider:
*
First
Last
PCP Phone:
PCP Phone:
-
###
-
###
####
Referred by:
Preferred Pharmacy Name/City:
*
Pharmacy Number
Pharmacy Number
-
###
-
###
####
Are you a self-pay patient?
*
Are you a self-pay patient?
Yes
No
Upload a copy of your primary insurance card (You may select more than one file. Each file cannot be more than 2MB.)
*
Attach Files
Upload a copy of your Picture ID (You may select more than one file. Each file cannot be more than 2MB.)
*
Attach Files
Insurance Type:
*
ID Number
*
Group Number
*
Insurance Phone Number
Insurance Phone Number
*
-
###
-
###
####
Subscriber Name
Subscriber Name
*
First
Last
Subscriber Date of Birth
Subscriber Date of Birth
*
/
MM
/
DD
YYYY
Emergency Contact:
Emergency Contact:
First
Last
Relationship to Patient:
Emergency Contact Phone Number
Emergency Contact Phone Number
-
###
-
###
####
How did you hear about Oasis?
*
RELEASE OF INFORMATION
Please confirm one of the following
*
RELEASE OF INFORMATION
Please confirm one of the following
I do not allow release of my information
I allow Release of my information
I authorize Oasis, the Center for Mental Health and independent practitioners providing services for or under Oasis to release of any medical or other information necessary to process a claim and/or for continuity of care purposes.
*
Clear
Name
Name
First
Last
Relationship to Patient
Date
Date
/
MM
/
DD
YYYY
I authorize all third party payments for services rendered to me by Oasis to be paid directly to Oasis, the Center for Mental Health.
*
Clear
Date
Date
/
MM
/
DD
YYYY
I have been given an opportunity to review and/or receive a copy of the HIPAA Notice of Privacy Practices.
*
Clear
Date
Date
/
MM
/
DD
YYYY
I understand that I am responsible for any co-pay, coinsurance, unmet deductible amounts and/or any fees not covered by insurance at the time of my scheduled appointment. I also understand that I will be responsible for the full fee for any missed appointment as stated in our welcome letter.
*
Clear
Date
Date
/
MM
/
DD
YYYY
I understand that in order to maintain active status with Oasis, Patients must attend an appointment every 60 days for therapy and 90 for medication management.
*
Clear
Date
Date
/
MM
/
DD
YYYY
Card on File Policy- Effective Sept 1, 2021
Oasis, The Center for Mental Health is now requesting patients keep a card on file for automatic payment of patient responsibility. Cards are kept in a secure database and will only be charged after a patient has completed their visit with us and their provider has signed off on their encounter.
I have read and understand the Card on File policy.
*
Clear
Date
Date
/
MM
/
DD
YYYY