Name *

First Name

Last Name

Phone *

We will need to contact you so we need a valid phone number.

(###)

###

####

Please check box if we can can leave a message or send an email *

Often we try to get a hold of patients and need to leave a message. May we leave a message

Cell Phone

e-mail

TXT message

Are you interested in seeing:

Dr Jeffrey Hedge Psychiatrist

Mr Randy Hendricks MS LMHC

Both

If you are interested in seeing Dr. Hedge are you currently seeing a Therapist

Yes

No

Are you looking for medication management?

Yes

No

What type of insurance do you have? *

Below are the types of insurance companies that we work with. If you do not have insurance you can pay fee for service.

ASURIS

PREMERA, BLUE CROSS, LIFEWISE

REGENCE

AETNA

HEALTHCARE MGMT ADMN

AMERIBEN

Kaiser Psychiatry only - authorization required

TriCare - authorization from TriCare required

FEE FOR SERVICE if we do not have a contract w/your insurance.

If you chose Fee For Service above do you have the following: *

Please let us know if you have the following insurance if you have Medicare you can not pay fee for service and we do not take any form of Medicaid.

Medicare

Medicare Advantage

Medicaid

Molina

Apple Health

State Insurance

No I have valid insurance that I checked from the previous question.

I understand that the providers at Integrative Psychiatry and Psychology require my payment that is estimated to be due at the time of service. *

If you are asked to fill out a new patient form you will be required to sign forms stating that you will pay your patient responsibility at the time of service.

Yes I understand

No