Becoming A New Patient

Download, complete, and return the 'Patient Acceptance Request' PDF form below. 

Patient Acceptance Request Rev 20210421.[...]
Adobe Acrobat document [113.5 KB]

Check with your insurance company to ensure that at least one of the providers at Crossroads is in-network for your specific insurance plan.  Also keep in mind that Crossroads does not offer chronic opiate (narcotic) or benzodiazepine management.

 

This form can be dropped off at our office, mailed, faxed, or emailed to the clinic at your convenience.  Feel free to call the clinic for more information or if you have problems downloading this form.  New patient requests are typically processed within 5 business days.

 

Crossroads is not currently accepting new patients whose primary coverage is Medicaid (or a Medicaid managed care plan).  This includes anyone applying for or with a pending Medicaid application.

 

Once accepted as a patient at Crossroads, you will need to download, complete, and return all the forms included in the 'Patient Packet' below.  Also, newly accepted patients MUST update the name of their primary care provider with their insurance carrier prior to their first visit to allow for proper claim processing - failure to do so may result in the patient being personally responsible for the entire amount of all claims until this has been completed.

Patient Packet Rev 20210421.pdf
Adobe Acrobat document [209.3 KB]
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