Sol Psychiatry PLLC | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Administrative

Who can we thank for referring you?

Moonstone Therapist for KAP Med Eval My Therapist Current Sol Client Other

Driver's license upload

Do not upload sensitive financial information such as credit card information.

The following providers are accepting new clients. Please select your preferred provider below:

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Please enter your Policy/Member ID and Group number. **If you do not have insurance, you can upload duplicate copies of your drivers license in the next question to move forward.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Insurance Company Name

Please select your insurance carrier from the list below. If your insurance company isn't listed, our services will most likely be private pay.

Are you the primary subscriber on this insurance policy?

Yes. I am the policyholder. No. I am a family member covered on this policy.

Name of Policyholder:

Policyholder's DOB:

For insurance billing purposes only: What gender is listed with your insurance plan?

*We understand this may not reflect your identity, and we’re happy to use your affirmed name and pronouns in all other settings.

**FOR MEDICARE CLIENTS ONLY** Please provide your SSN for verification purposes.

(If you do not have a Medicare plan, please enter "NA".)

Client Preferences

Is there anything that the practitioner needs to know?

For example: What would you like to focus on? Do you have insurance or payment questions? Please also mention if you were referred by Moonstone for a Med Eval.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.