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Insurance Submission

If you have difficulty submitting this form, click here and 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 필수
Does the patient have secondary insurance 필수
Does the patient have a guardian? 필수
Is the patient of Hispanic or Latin origin? 필수
Has the patient participaed in a self-help group in the past 30 days? 필수
Is the patient a veteran? 필수
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? 필수
Are you a hurricane victim 필수
Is the patient currently recieving mental health treatment 필수
Any arrests in the past 30 days? 필수
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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