Take Your First Step Towards a Brighter Future Send us a Request, and we'll get back to you Shortly You can fill out the patient registration form below with your personal information and request the next available appointment online or over the phone Name: Email: Phone: Address: City Zip Date of Birth: Do you have insurance or self-pay? InsuranceSelf-Pay Insurance provider: (Note: If you have a different insurance provider please call or email our office to check eligibility. —Please choose an option—AetnaBeaconBlueCrossBlueShieldCignaHealthNet/MHNMagellan HealthcareMedicarePartnership Health PlanTricareTriwest Member ID: Insurance phone number from the back of the card: Name and ID Number of secondary insurance (If applicable): Please upload the front and back of your insurance card. Medical Service: (TMS) Transcranial Magnetic StimulationMedication ManagementPsychotherapyESKETAMINE Reason for the visit: How did you find out about us? Medical ReferralPsychiatry TodayZocdocWebsiteOther Privacy Policy: I have read and acknowledged the Privacy Policy and agree to settle all bills as they are presented. For members with private insurance plans, I will cover all deductibles, co-payments, and patient responsibility portions of the bill, in accordance with the specific plan. I acknowledge and agree to pay a cancellation fee of $55 for any appointment cancelled with less than 24-hour notice. Additionally, I understand that it is my responsibility to inform the office promptly of any changes in my insurance coverage. Telepsychiatry only works if the highest level of confidentiality is met. The audio and video data streams constitute protected health information (PHI) protected under HIPAA. Segal Telepsychiatry ensures confidentiality by encrypting all of the data (audio + video) in its videoconferences end-to-end from within our software. All communications are sent using 256-bit AES encryption. We take appropriate measures to comply with the all HIPAA privacy and security rules. I consent to receiving PHI by email. I understand that the physician assistants are licensed and regulated by the physician assistant board. Δ Having trouble filling our application online? Please call our office 866-247-4292 Or Use this Form Instead