Admission Inquiry - OUTPATIENT
First Name:
Last Name:
Maiden Name:
Email Address:
Date of Birth:
Phone Number
What location would you prefer to contact you?
Select an option
Hudson, NY
Catskill, NY
Insurance
Select One (Choose "Other" if Not Listed)
NYS Medicaid
CDPHP
Fidelis
MVP
United Healthcare
Empire Blue Cross/Blue Shield
Optimum HealthCare
Aetna
Other Please List Below
None
If Other Insurance
Insurance Number (If none N/A):
Please select your housing situation at the time of this application
Select an option
Private Residence
Homeless
Shelter
Corrections
Inpatient/Hospital/Rehab
Other
If Other, please provide details
Do you inject non-prescription drugs using a needle/syringe?
Yes
No
Are you currently pregnant?
Yes
No
Your Signature
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Todays Date
Upload any Supporting Documentation
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I attest that all information provided is accurate and complete
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