Prospective Patient Form

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The admissions process at Eating Recovery Center begins with a comprehensive assessment of each patient’s medical, psychological and sociocultural history and thorough verification of the health benefits available. Together with guidance from the Clinical Assessment team, this information helps patients and families make informed decisions about pursuing and financing eating disorder treatment.

Patient Assessment Form

1 Instructions

2 Patient Information

3 Insurance Information

4 Outpatient Team

Instructions
Please complete the form below to the best of your ability, and don’t hesitate to contact the Clinical Assessment team with questions or concerns by calling 877-825-8584, or click the Chat icon in the upper-right corner of this screen to chat live with a Master’s level clinician. Upon receipt, the Clinical Assessment team will begin the benefits verification process and contact you with information about next steps in the patient assessment process.

Please note that Eating Recovery Center cannot begin the benefits verification process unless this form is completed in its entirety.

Full Legal Name*
Date of Birth*
Mailing Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone Number*
Email Address*
Preferred Method of Contact*
- Phone
- Email
- Mail
Is there a method of contact we cannot use?
- Phone
- Email
- Mail
How did you hear about us?

Instructions
This information should be readily available to you by reviewing your insurance card. If you cannot locate your insurance information, we encourage you to contact your insurance company and complete this form following that conversation. Please note Eating Recovery Center cannot begin the benefits verification process if any Insurance Information fields are empty upon submission. It will be the responsibility of the patient to contact the Clinical Assessment department with any missing information, after which they will begin processing insurance benefits.
Insurance Company*
Insurance Company Phone Number*
Insurance Party (Policy Holder)*
Policy Holder Date of Birth*
ID Number*
Group/Account Number*
Employer*
Group/Account Number*
Rx Group Number*
Communicate Benefits to*

Outpatient Team
If you currently have relationships with the following types of providers please provide their name and contact information. If you do not currently have relationships with the following types of providers, leave the fields blank or insert “Not Applicable.” Please note that Eating Recovery Center CANNOT contact any of your outpatient providers without a signed release of information.
Therapist
Family Therapist
Dietitian
Psychiatrist
Primary Care Physician
Other
Comments
This field is for validation purposes and should be left unchanged.

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