Patient Information
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Midwest Behavioral Health reserves an appointment time just for you. Please be considerate and inform us within a reasonable amount of time if you need to cancel or reschedule. We reserve the right to charge a fee of $35 for a late cancelation or no showed appointment. We require a 24 hour notice so that we may fill your appointment time with another patient. *
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Patient Employer Information:
(if patient is over 18)
Physician/Pharmacy Information:
Emergency Contact:
I give my consent to MWBH providers and/or staff to contact the following person(s) in the event of an emergency:
If patient is a minor:
This section is required to be completed by parent/guardian. 

MWBH does not participate with Medicare or Medicaid. If you are covered by one or more of these plans please contact the office immediately (812)401-8008.

Primary Insurance:
Prior to any appointments with MWBH contact your insurance provider to verify your coverage and to check your mental health benefits.  The phone number can usually be found on the back of your insurance card.
 
*Request to specifically speak with a representative regarding your "Behavioral Health benefits".
 
*Many Behavioral Health benefits are managed by a different insurance carrier than your medical carrier.  This is referred to as a "carve out".  If your benefits are carved out to another company, note the address that claims are sent to and verify that our providers are in network. 
Verified Benefits: *
Authorization Required: *
My behavioral health benefits are handled by another company other than my primary insurance (This is referred to a Carve Out).  *
Behavioral Health Coverage:
(fill out if you answered Yes to the above question)
Secondary Insurance:
Verified Benefits:
Authorization Required: