Patient Registration Step 1 of 9 11% STOP Before Completing, please contact your insurance company to see if our services are covered (GETTING THE MOST FROM YOUR INSURANCE COMPANY). We are an "Out of Network" practice except for Federal (NOT MANAGED) Medicare. Todays Date* MM slash DD slash YYYY Current Complaint*Current Medications* Patient InformationFirst name*Middle NameLast Name*Prefix*--Select Prefix--Mr.Mrs.Ms.Dr.Prefix*--Select Marital Status--SingleMarriedDivorcedSeparatedWidowedPhone*Date of Birth* Month Day Year Age*Please enter a number from 1 to 120.Sex*--Select Sex--MaleFemaleOtherEmail Enter Email Confirm Email Referred ByAddress* Street Address Address Line 2 City State --State--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 ZIP Code Do you have health Insurance?* Yes No Primary Care DetailsDoctor Name or Name of Practice*Phone*Pharmacy DetailsPharmacy Name*Phone* InsuranceInsurance Company*Group Number*Policy Number*Mailing Address for claims (as listed on back of insurance card) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insurance Phone Number (as listed on the back of insurance card)Is the subscribers name and address information the same as the patient?* Yes No Secondary Insurance?* Yes No Subscriber's InformationLeave this section blank and proceed to the next view if the Subscriber Patient information are the same.Subscriber's First NameSubscriber's Middle NameSubscriber's Last NameDate of Birth MM slash DD slash YYYY Phone NumberAddress Street Address Address Line 2 City State 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 ZIP Code Patient's Relationship To SubscriberSecondary Insurance?* Yes No Secondary InsuranceInsurance Company*Group Number*Policy Number*Mailing Address for claims (as listed on back of insurance card) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insurance Phone Number (as listed on the back of insurance card)Is the subscribers name and address information the same as the patient?* Yes No Subscriber's InformationLeave this section blank and proceed to the next view if the Subscriber Patient information are the same.Subscriber's First NameSubscriber's Middle NameSubscriber's Last NameDate of Birth MM slash DD slash YYYY Phone NumberAddress Street Address Address Line 2 City State 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 ZIP Code Patient's Relationship To Subscriber In Case of EmergencyName of Friend or Relative*Relationship to Patient*Phone Number* Agreement* The information entered in this form is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the healthcare provider. I understand that I am financially responsible for any balance due. I also authorize Advanced Behavioral Counceling of Northern NJ, LLC or insurance company to release any information required to process my claims. Signature*Reset to re-sign.Digital Signature Agreement* I understand that checking this box along with the digital signature above, constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information on this form. NameThis field is for validation purposes and should be left unchanged.