Relapse Prevention | OhioGuidestone

OhioGuidestone Relapse Prevention Form

Client Last Name

Client First Name

Date of Birth

Social Security Number

Gender

Street Address

City

State

Zip Code

Please enter your 9 digit zip code in the xxxxx-xxxx format. If you do not know your +4 zip code, enter your address on this page at the USPS website.

Do you give permission to receive text messages for scheduling purposes if you have shared your cell phone number below?

Yes
No

Phone (cell/home)

Email

Funder/Payor/Contract

Permission obtained to verify benefit eligibility?

Yes
No

Funding Type

Household Size

Please enter the number of people living in your household

Monthly Gross Income

Please enter the total monthly income amount before taxes for all household members

Source of Income

Medicaid Managed Care Plan

Medicaid Care ID#

Medicaid MMIS#

Private Insurance Company

Employer

Policy Holder Name

Policy Holder Relationship

Policy Holder Date of Birth

Policy Holder Social Security Number

Policy Holder Address

Policy Holder Phone

Policy Number

Group

Customer Service Phone Number

Name of Funding Source

Contact Name

Contact Phone

Medicare ID#

Part

MyCare Plan Name

MyCare ID#

Customer Service Phone Number

If you'd like, you can PRINT A COPY OF THIS RECORD before submitting this form. You can also request a copy from your OhioGuidestone provider.