Online New Patient Information Form Non-Contracted Insurances If you have United Commercial, Tricare or Humana we are not contracted with your insurance company. We would be happy to see you as a self pay patient but will be unable to bill insurance on your behalf. New Patient Insurance Verification Form Please fill out this form if you are interested in becoming a New Patient with Sage Neuroscience Center. Once submitted, our new patient coordinator will work on verifying your insurance and contact you to schedule an appointment. Basic Patient InformationName* First Last Middle InitialAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Social SecurityGender*MaleFemaleDate of Birth MM DD YYYY Email Please include email if you would like a copy of this form. Services Needed* Individual Therapy Couples Therapy Family Therapy Group Therapy Child Therapy TMS Therapy Medication Management Addiction Treatment Behavioral Health Intensive Outpatient Program Primary Care Medically Assisted Detox Addictions IOP Other Please select all that apply.Addiction Type Alcohol Opioids (prescription pain meds, heroin, etc) Other (If you are under the care of a provider for any of these concerns, Sage requires a referral from your provider to be considered in the program.) Other ServicesWhat type of services are you looking for?Will someone else be scheduling appointments?*YesNoBy selecting "yes" you grant Sage Neuroscience Center permission to contact listed individual in order to schedule your appointments.Name of person scheduling* First Last Phone*Insurance InformationDo you have insurance?*Yes - Commercial InsuranceYes - Medicare / Advantage / SeniorYes - Medicaid / CentennialNo, I would like to self pay.Commercial Insurance*Blue Cross / Blue ShieldAetnaMolinaPresbyterianNew Mexico Health ConnectionsMedicare*Blue Cross Senior / Medicare AdvantageAetna Senior / Medicare AdvantageMolina Senior / Medicare AdvantagePresbyterian Senior / Medicare AdvantageMedicareMedicaid*Blue Cross CentennialUnited CentennialMolina CentennialPresbeterian CentennialMedicaidName of Primary Insurance Policy*Primary Policy Holder's Name*Group NumberID Number*Please include any letters that precede the ID number.Phone Number on Back of CardPlease provide us with the phone number from the back of your insurance card, this will help for faster verification.Policy Holder's Date of Birth MM DD YYYY Relationship to Insured*Enter self if you are policy holder. Otherwise indicate spouse, parent, child, or other.Do you have a secondary insurance?*Yes - Commercial InsuranceYes - Medicare / Advantage / SeniorYes - Medicaid / CentennialNoCommercial Insurance*Blue Cross / Blue ShieldAetnaMolinaPresbyterianNew Mexico Health ConnectionsMedicare*Blue Cross Senior / Medicare AdvantageAetna Senior / Medicare AdvantageMolina Senior / Medicare AdvantagePresbyterian Senior / Medicare AdvantageMedicareMedicaid*Blue Cross CentennialUnited CentennialMolina CentennialPresbeterian CentennialMedicaidSecondary Insurance Policy Name*Secondary Policy Holder's Name*Secondary Insurance Group NumberSecondary Insurance ID Number*Please include any letters that precede the ID number.Secondary Date of Birth* MM DD YYYY Relationship*Enter self if you are policy holder. Otherwise indicate spouse, parent, child, or other.How did you hear about Sage?*Referred by primary care / medical providerReferred by therapist / counselor / psychiatristReferred by InsuranceA friend or familyOnline search / googlePublication / MagazineHave been aware of Sage for some time.Who Referred you?Let us know who referred you so we can say thank you. By submitting this form, you grant Sage Neuroscience Center permission to contact you and your insurance concerning scheduling of services. Newsletter SignupWould you like to be added to our Email Newsletter? Yes, I would like to receive general updates from Sage Neuroscience Center to my E-mail. Please be sure to attend your first appointment with Sage - if you miss it, you will not be able to reschedule the appointment for the next 12 months. This iframe contains the logic required to handle AJAX powered Gravity Forms.