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

For Documents

Upload Front of Insurance Card

For Documents

Upload Back of Insurance Card

For Documents

Upload Gov Issued ID

Type of Referral

Self

Parent/Guardian

Professional

Professional-Non Therapeutic

Does the patient have secondary insurance

Yes

No

Does the patient have a guardian?

Yes

No

Is the patient of Hispanic or Latin origin?

Yes

No

Has the patient participaed in a self-help group in the past 30 days?

Yes

No

Is the patient a veteran?

Yes

No

Is the patient pregnant? (Female only)

Yes

No

For Pictures

Upload Front of Insurance Card

For Pictures

Upload Back of Insurace Card

For Pictures

Upload Gov Issued ID

Do you have the primary care info?

Yes

No

Are you a hurricane victim

Yes

No

Is the patient currently recieving mental health treatment

Yes

No

Any arrests in the past 30 days?

Yes

No

Upload additional document

Upload File

Your Signature

Thanks for submitting!