PCP pre-registration Form "*" indicates required fields NOTE: A photo ID must be uploaded with this form in order to process your registration. You may take a photo of your ID and other supporting documents, and upload as instructed below. If you have health insurance , please include photos of the front and back of the insurance card. You can upload these images utilizing this form or send them to PCAdmissions@smhwi.com once these steps are completed and the admissions representative will call you to schedule an appointment. When this form is completed an email will be sent to you with instructions on how to set up your patient portal and how to complete your intake forms. Thank you!Patient Name First Last Patient Date of Birth MM slash DD slash YYYY Sex (assigned at birth) Male Female Patient Address: We can only treat Patients with in ArizonaAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Emergency Contact Name PhoneEmergency Contact Relationship Please select a Payment Option: Cash Pay (No Insurance) Military Insurance Commercial Insurance Medicare Part A and B Medicare Part A and B with Supplementary Secondary Insurance Who referred you or source of referral: Treatment of services Needed: Annual Preventive care visit Women's Health Chronic Health Problems Other If other* Reason(s) for appointment/ additional information:Upload Front and back of insurance cardMax. file size: 256 MB.Upload ID / Drivers licenseMax. file size: 256 MB. **( patients using insurance will need to provide insurance cards prior to getting on the schedule)* PhoneThis field is for validation purposes and should be left unchanged.
