Enter New Client Administrative and Insurance Information
Use This Form Only After You Have Scheduled An Appointment With A Provider.
If you do not have an appointment, and are interested in being a
client Click Here.
Some administrative information needs to be gathered before referring you to a
By clicking below you will be directed to a web form that will allow you to enter all the
administrative and insurance information that is necessary to collect before a first appointment with an Associated
You will be prompted to enter the following:
1. Patient/client information.
2. Subscriber(s) information.
3. Person financially responsible.
4. Detailed insurance information. (Please have your insurance information on hand.)
5. Name of our provider and date of initial appointment.
Please Note: All of the above information is required. If you do not have this information you will not
be able to complete your form.
This information will be forwarded securely to our office staff. You will have the option of receiving a secure
link where you may view the information you have sent to the office.
Once the form has been completed and submitted electronically, you will have the option to print the additional
paper forms that require an original signature.
You may print these forms, sign them and bring them to the office at your first appointment. If you do not print
these forms, they will be made available at our office.
Page Last Updated: 12/02/11