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Insurance Submission

If you have difficulty submitting this form, email a copy of the form to admin@oneheartt.org

Front and back of insurance card and government ID are required

Upload Front of Insurance Card
Upload supported file (Max 15MB)
Upload Back of Insurance Card
Upload supported file (Max 15MB)
Upload Gov Issued ID
Upload supported file (Max 15MB)
Type of Referral Bắt buộc
Does the patient have secondary insurance Bắt buộc
Does the patient have a guardian? Bắt buộc
Is the patient of Hispanic or Latin origin? Bắt buộc
Has the patient participaed in a self-help group in the past 30 days? Bắt buộc
Is the patient a veteran? Bắt buộc
Is the patient pregnant? (Female only)
Upload Front of Insurance Card
Upload supported file (Max 15MB)
Upload Back of Insurace Card
Upload supported file (Max 15MB)
Upload Gov Issued ID
Upload supported file (Max 15MB)
Do you have the primary care info? Bắt buộc
Are you a hurricane victim Bắt buộc
Is the patient currently recieving mental health treatment Bắt buộc
Any arrests in the past 30 days? Bắt buộc
Upload File
Upload supported file (Max 15MB)

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Friday                                  9AM until 2PM

   ​Saturday                             10AM until 1 PM

Sunday                                Closed

 

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