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.