Blackstone NP In Psychiatry PLLC

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

Administrative

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How do you plan to pay?

Primary Insurance Information

Please provide the insurance company name and any additional information that may help us verify your benefits (member ID, subscriber name if different from yours, etc.).

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Limited to 600 characters

Is there anything else you would like us to know before reviewing your request?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Emergency Acknowledgment

I understand that Blackstone NP In Psychiatry PLLC does not provide emergency or crisis services. If I have a medical emergency I will call 911. If I have a mental health crisis I will call or text 988 or go to the nearest emergency department.

Yes

Permission to Contact

I consent to Blackstone NP In Psychiatry PLLC contacting me regarding scheduling, appointments, billing, and care coordination using the phone number and email address I provided.

Yes

Permission to Receive Text Messages

I consent to receive appointment-related text messages from Blackstone NP In Psychiatry PLLC. Message and data rates may apply. Consent is not required to receive treatment.

Yes

Acknowledgement

I understand that submitting this prescreening form does not establish a provider-patient relationship

Acknowledgement

I understand that submitting this form does not guarantee acceptance into the practice or an appointment

Acknowledgement

I understand that insurance verification is a courtesy and is not a guarantee of coverage or payment.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.