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Intensive Outpatient Programs - Intake Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Sex
Male/Female/Other
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Source (If applicable)
How did you hear about our IOP?
Best time to call
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Relationship
Please enter a valid phone number.Format: (000) 000-0000.
In the past week,have you had thoughts of harming yourself or ending your life?
FOR MEDICAID RECIPIENTS ONLY
Name of Insurance Company
Member ID Number
Medicaid ID Number
PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:
Do you have insurance?
Insurance Front Side

Cancelof
Insurance Back Side

Cancelof
Additional Insurance Information
Name of Policy Holder
DOB of Policy Holder

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Client
Place of Employment
Name of Insurance Company
Member ID
Annual Deductible Amount
Group Number
Copay Amount
Is there anything you would like to share that would be helpful to the person reaching out to further discuss this with you?

Authorizations:
Release of Information to Insurance Company (Please check that you understand):
Authorization for Medical Treatment (Please check that you understand):
Power of Attorney

I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect the care I receive from the provider, my eligibility for benefits, or enrollment, payment, or coverage of these services.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name of Legal Representative

First NameLast Name
Signature of Legal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human

HIPAA Release of Information Authorization Form

GetWell Health System(GWHS)
I hereby authorize GWHS and its affiliates, employees, and agents to release information to:
My or my legal dependents person health information is maintained by GWHS (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided and which identifies me or my legal dependents name, address, social security numbers, and member ID number) except the following information:
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Authorization for Release of Information
Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
I authorize GetWell Health System to disclose my medical records to:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
I authorized North Clark Medical Group to obtain my medical records from:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released prior to the written revocation. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to consent under my policy. Unless otherwise revoked, this authorization will expire on the below date. If I fail to provide an expiration date, this authorization will expire in 60 days from date of signature.
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness name

First NameLast Name
Witness Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

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DISCLAIMER: Providers within the GetWell Health System network are independent contractors, with limited exception, who are not employees of Get Well Health System. Independent contractors are responsible for their own work hours, liability coverage, and patient treatment plans.

Intensive Outpatient Programs - Intake Form

FOR MEDICAID RECIPIENTS ONLY

PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:

Authorizations:

Power of Attorney

HIPAA Release of Information Authorization Form

Authorization for Release of Information

I authorize GetWell Health System to disclose my medical records to:

I authorized North Clark Medical Group to obtain my medical records from:

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