RMBI Contact Form

Personal Information

First name*Last name*Date of birthSex / genderPronounsEmail*Mobile phone*Alternate phoneStreet addressApt / unitCityStateZIPCounty

Emergency Contact

Full nameRelationshipPhone

Insurance & Coverage

Primary insurance carrierMember IDGroup #

Coverage flags

MedicaidMedicareUninsured / sliding scaleSelf-pay

Reason for Visit

Consent & Signature

I authorize RAIN by RMBI to contact me using the information above, to verify insurance coverage, and to provide assessment and treatment as clinically appropriate. I understand my information is protected under HIPAA and will not be shared without my written consent except as required by law.

Typed signature (your full name)*I have read and agree to the consent statement above.