psychvisit

In-Office Check-In

Complete all sections before your appointment

Patient Information

First Name *

Last Name *

Date of Birth *

Select date of birth

Phone *

Insurance Information

Has your insurance changed? *

Insurance Carrier *

Member ID *

Group Number

Policy Holder Name

Insurance Card — Front *

Tap to upload front of card
JPG, PNG, PDF — Max 10 MB

Insurance Card — Back *

Tap to upload back of card
JPG, PNG, PDF — Max 10 MB

Photo ID (optional)

Tap to upload photo ID
Optional — helps verify identity

Pharmacy

Would you like to update your pharmacy? *

Pharmacy Name *

Address *

Phone

Fax

Preferred Type

Visit Type *

Quick Refill Visit Medication refill with brief check-in — 10-15 min

Extended Visit In-depth discussion, medication adjustment, new concerns — 25-30 min

Follow-Up Routine follow-up appointment — 15-20 min

Reason for Visit *

Consent & Acknowledgement

Payment Method *

Private Pay — $175.00 Established follow-up visit fee

Suboxone/MAT — $225.00 Suboxone management, refill & compliance visit

Emblem/Legacy — $125.00 Reduced insurance rate (recent loss of membership)

No Payment Required Skip payment — not needed for this visit

Insurance Co-Pay Enter your insurance co-pay amount

Custom Amount Enter a custom payment amount

You're Checked In

Your check-in is complete. Please have a seat in the waiting room and your provider will be with you shortly.

A confirmation text has been sent to your phone.