Linden Oaks Business Office - Patient Registration Form

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Patient Information- Patient Registration

Fill out the below information for the patient (individual who is being assessed/treated). If you have questions regarding this form, contact the Linden Oaks Business Office at 630-305-5096. Please note: Withholding insurance coverage from this registration may result in non-coverage of services. Please enquire with our business office about the insurance companies that Linden Oaks is in-network with. Google Chrome is the preferred browser to open this form.

Today's Date*

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Month

Day

Year

Patient Name*

First Name*

Initial*

Last Name*

Legal Sex: *

Male Female

We use this information when communicating with your insurance company. Please indicate the sex listed on your driver's license or state ID. Please provide any additional sex, gender, or gender identity information in the additional comments section.

Preferred Name

First Name

Initial (optional)

Last Name

Patient Date of Birth*

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Month

Day

Year

Preferred Pronouns:

Gender Identity:

Do you identify with the sex you were assigned at birth?*

Yes No

Sexual Orientation*

Race*

Ethnicity:*

Preferred Language: *

Patient Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Are you a minor (under the age of 18 years old)?*

No Yes

Patient Preferred Phone Number*

Cell Phone Home Phone

Patient Cell Phone*

Patient Home Phone Number

Patient Work Phone

Patient Home Phone*

Patient Cell Phone

Patient Work Phone

Patient Email*

Patient Social Security Number

Patient's Religion/Church Name (if applicable)

Upload the FRONT of your driver's license or state identification (ID) card (if possible).

No File Chosen

File uploads may not work on some mobile devices.

Upload the BACK of your driver's license or state identification (ID) card (if possible).

No File Chosen

File uploads may not work on some mobile devices.

Patient Marital Status*

Single Married Divorced

Other: Other Value

Patient Military Status (if applicable)

Patient Employment Status*

Full-time Employee Part-time Employee Not Employed Retired Student Disabled

Other: Other Value

Patient Employer Name*

Patient Employer Address*

Address Line 1

Address Line 2

City

State

ZIP Code

EMERGENCY CONTACTS

Name (Primary)

First Name

Last Name

Relation to Patient (Primary)

Address (Primary)

Address Line 1

Address Line 2

City

State

ZIP Code

Phone (Primary)

Name (Secondary)

First Name

Last Name

Relation to Patient (Secondary)

Address (Secondary)

Address Line 1

Address Line 2

City

State

ZIP Code

Phone (Secondary)

GUARANTOR (Individual responsible if under 18)

Guarantor is the individual who accepts financial responsibility to pay the patient's bill.

If the patient is minor (under the age of 18), the responsible party is usually the minor's parent or legal guardian.

The guarantor should not be confused with the subscriber/policy holder of the insurance. This may or may not be the same person.

Name *

First Name*

Initial*

Last Name*

Guarantor DOB:*

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Month

Day

Year

Gender

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

SSN:

Employer Name

First Name

Last Name

Employer Address

Address Line 1

Address Line 2

City

State

ZIP Code

INSURANCE COVERAGE

If no insurance SUBMIT at the end of the form

Do you have insurance? *

Yes No

yes

Are you (the patient) the policy holder on your primary insurance? *

Yes, I (the patient) am the policy holder No, I (the patient) am NOT the policy holder

Primary Insurance Coverage

Primary Insurance Name*

Primary Insurance Member ID # *

Primary Insurance Group #*

Upload a picture of the FRONT of primary insurance card (if possible)

No File Chosen

File uploads may not work on some mobile devices.

Not required but encouraged

Upload a picture of the BACK of primary insurance card (if possible)

No File Chosen

File uploads may not work on some mobile devices.

Not required but encouraged

Policy Holder Name*

First Name*

Last Name*

Policy Holder's relationship to the patient*

Mother Father Spouse Self Dependant

Other: Other Value

Policy Holder Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Policy Holder Date of Birth *

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Month

Day

Year

Policy Holder Gender*

Female Male

Other: Other Value

Policy Holder Social Security Number

Policy Holder Employer

Policy Holder Employer Phone

Policy Holder Employer Address

Address Line 1

Address Line 2

City

State

ZIP Code

Secondary Insurance Coverage (If applicable)

Do you (the patient) have secondary insurance?*

No Yes

Are you (the patient) the policy holder on your secondary insurance?*

Yes, I (the patient) am the policy holder No, I (the patient) am NOT the policy holder

Primary Insurance Name*

Primary Insurance Member ID # *

Primary Insurance Group #*

Upload a picture of the FRONT of secondary insurance card (if possible)

No File Chosen

File uploads may not work on some mobile devices.

Not required but encouraged

Upload a picture of the BACK of secondary insurance card (if possible)

No File Chosen

File uploads may not work on some mobile devices.

Not required but encouraged

Policy Holder Name*

First Name*

Last Name*

Linden Oaks Behavioral Inventory

Did someone refer you to Linden Oaks for an assessment?*

No Yes

Name of the individual who referred you to Linden Oaks for an assessment ?*

Phone number of the individual who referred you for an assessment ?

Patient Concerns/Issues

What concerns/issues are you here for?*

Depression Anxiety/Panic attacks Self-injury Psychosis Loss of usual functioning Suicidal thoughts Thoughts or actions to hurt others Anger/Verbal Aggression Anorexia/Restricting food Bulimia/Purging food Binge eating Substance use Detox/withdrawal

Other: Other Value

List substances used*

Race/Ethnicity - Copy

Hospitals are required to record a patient's race and ethnicity following the current federal standards. These standards have been developed to provide a common language for uniformity and comparability in the collection and use of data on race and ethnicity.

What is your race?*

White Black/African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander

Other: Other Value

Are Hispanic, Latino or of Spanish origin?*

No Yes

Answer these questions based on your (the patient's) thoughts and actions in the last seven days.

In the past 7 days, have you wished you could go to sleep and not wake up?*

No Yes

In the past 7 days, have you had any thoughts of killing yourself?*

No Yes

Have you thought or been thinking about how you might kill yourself?*

No Yes

In the past 7 days, have you had thoughts or taken actions to hurt others?*

No Yes

In the past 7 days,have you intentionally injured yourself?*

No Yes

If yes, when did you injure yourself?

Medical Information

Have you experienced any of the following within the past 7 days? (Check all that apply)*

Nausea Vomiting Diarrhea Chills Fever Sweating Cough Rash None

Other: Other Value

Have you recently been exposed to anyone who had a contagious illness?*

No Yes

If yes, what illness and when?*

Do you have a history of any of the following illnesses?*

MRSA C-diff VRE ESBL None of the above

Other: Other Value

Indicate all current medical conditions you have

Do you take any medication?*

No Yes

List Medications and Dosages*