Patient Application

Apply to become a new patient at Seaside Wellness of Navarre.

In order to provide the quality & efficient care for your individual needs, we want to ensure patients & providers are a great match for care. Please provide the information requested below so we can determine if our team may be able to meet your healthcare needs. Our clinicians will review your application along with the information provided. If we feel as though we are able to meet your needs after reviewing your information, we will contact you in a timely manner with our decision. Please allow additional time for the review process of your application due a high volume of new patient applications.

In an attempt to remain HIPAA compliant & within guidelines, please only complete this form if you are applying as yourself or a direct family member of the intended patient. If you are a provider or medical office, we ask that you instruct your patient to visit our website & apply for themself. Any applications submitted by or suspected to be submitted by providers or medical offices will be discarded of immediately.

Thank you,
Seaside Wellness Staff

Are you applying for yourself or on behalf of someone else? *

I'm applying for myself.

I'm applying on behalf of someone else.

Applicant information *

Patient Information:

Legal First Name *

Middle Initial *

Legal Last Name *

Date of Birth *

Age *

Assigned Sex at Birth *

Male

Female

Intersex

Mobile Phone Number *

Consent to Call & Text *

Yes

Email *

Consent to Email *

Yes

Street Address *

City *

State *

Zip Code *

Insurance:

Will this be billed under insurance? *

Yes

Policy Holder Information *

Please include the insurance policy holder's relation to the patient (self, child, spouse, other), the policy holder's legal first & last name, the policy holder's date of birth, & the assigned sex at birth of the policy holder.

Insurance Name *

Insurance Group Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Insurance Policy Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Do you have secondary insurance? *

Yes

Policy Holder Information *

Secondary Insurance Name *

Secondary Insurance Group Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Secondary Insurance Policy Number *

If you have TriCARE as your insurance, list the Benefits ID number (ending in a -00, -01, etc.).

Medical History:

Current Diagnoses: *

Current Medications: *

Please be advised that per clinic policy, we only prescribe ONE (1) controlled substance per patient at any given time.

Are you currently under the care of another provider? *

Yes

Name of Current Provider *

Current Provider's Facility Name *

Current Provider's Facility Address *

Current Provider's Phone Number *

Current Provider's Fax Number *

Consent to Contact Current Provider *

If we do not receive consent to contact current provider for medical records, we may not be unable to accept your application.

Are you in good standing with previous provider? *

Yes

Not applicable

Name of Previous Provider *

Previous Provider's Facility Name *

Previous Provider's Facility Address *

Previous Provider's Phone Number *

Previous Provider's Fax Number *

Consent to Contact Previous Provider *

If we do not receive consent to contact previous provider for medical records, we may not be unable to accept your application.

Please explain why you are not in good standing with your previous provider: *

We require 1-2 years of medical records to be faxed to us at least two weeks prior to a scheduled appointment. *

I understand & am willing to have medical records released.

I am NOT willing to have medical records released.

Additional Questions:

Why are you looking for care at Seaside Wellness of Navarre? *

Do you have a provider preference? *

No Preference/First Available

Yes, I prefer:

Please select the provider you prefer & we will take this preference into consideration.

What type of care are you seeking? *

Primary Care

Psychiatric Care

Counseling/Therapy

DISCLAIMER *

I understand that the type of care I am looking for does not include medication management for psychiatric needs or pain management. I am aware that I must separate psychiatric needs from primary care needs for insurance billing purposes & that I may be declined psychiatric services at the time of the appointment. I understand that I am eligible to be referred elsewhere in the event my needs are outside of the provider's scope of practice, including referrals for pain management & additional needs.

DISCLAIMER *

I understand that the type of care I am looking for does not include medication management of any kind. I am aware that services are currently Self Pay only & not billable through insurance. I am aware that I may be declined services or referred elsewhere in the event my needs are outside of the provider's scope of practice.

Have you ever been hospitalized for mental health? *

Yes

Please describe the hospitalization details: *

Have you ever visited a counselor/therapist before? *

Yes

Please describe your previous therapeutic experience: *

Are you willing to be an active participant in your healthcare plan, even if recommendations are for lifestyle changes including but not limited to exercise, focusing on nutrition & preventive wellness, &/or attending therapy or counseling if deemed necessary? *

Yes

Not being an active participant &/or being noncompliant in care plans may result in discontinued services & dismissal from the practice at the degression of the provider.

Terms of Service

I agree to willingly submit all provided information to Seaside Wellness of Navarre. All provided information is correct & up to date to the best of my knowledge.

Phone