Skip to Content
main
(713) 939-7272
Schedule an appointment online with ScheduleNow
Contact Us
Payment Options
Resources
Careers
Drug & Alcohol Rehab
Drug Treatment Programs
Customized Treatment
Program Elements
Family Services & Support
Services & Amenities
Our Rehab Programs
Teens (13-17)
Young Adults (18-24)
Adults (25+)
Professionals & Executives
Pain Recovery Program
Locations
Memorial Hermann Prevention and Recovery Center
Houston Locations
Take A Virtual Tour
Austin Intensive Outpatient Rehab
San Antonio Intensive Outpatient Program
Texas Cities We Serve
Get Started
Alcohol & Drug Rehab
Take Our Self-Assessment
How to Pay for Rehab
Admissions Process
What to Bring to Rehab
Visiting Hours
About PaRC
Physicians & Executives
Awards & Distinctions
PaRC Rehabilitation News
Articles & Publications
Resources
FAQs
Contact PaRC
Cameron Addiction Medicine Fellowship
Insurance and patient pre-admission information
*
= required fields
Insurance Information
Patient’s Last Name:
*
Patient’s First Name:
*
Patient’s Middle Name:
*
Patients Sex:
*
Male
Female
Patient’s Email Address:
*
Patient’s Social Security #:
*
-
-
Patient’s Date of Birth:
*
(mm/dd/yy)
Patient’s Phone #:
*
(
)
-
Patient’s Cell #:
(
)
-
Name of Insured Person:
*
Relationship to patient:
*
Select
Husband
Wife
Mother
Father
Friend
Grandparent
Other
Insured’s Date of Birth:
*
(mm/dd/yy)
Insured’s Social
Security #:
*
-
-
Insured’s Phone#:
*
(
)
-
Yes, I am the patient. My address (city, state and zip) is:
*
No, I am
not
the patient. My address (city, state and zip) is:
(If
not the patient
, complete the patient’s address below)
Patient’s address (city, state, and zip) is:
Insured’s Employer:
*
Name of Insurance:
*
Insurance Phone #:
*
(
)
-
Insured Employer Phone #:
*
(
)
-
Group Name:
Policy /ID #:
*
Group#:
*
Name of Person who referred the patient:
*
Patient Information
Former Patient (y/n):
*
yes
no
Referred By:
Date:
Time:
Martial Status:
*
Select
Married
Single
Primary Language:
Does the patient have any religious needs?:
*
no
(if yes, please explain)
yes
Occupation:
Status
Select
Full time
Part time
Retired
Other
Patient’s Employer Address:
*
Patient’s Employer Phone#:
*
(
)
-
Nearest Relative
Last Name:
First Name:
Phone: (
)
-
Address:
Relationship to Patient:
Select
Husband
Wife
Mother
Father
Friend
Grandparent
Other
Emergency Contact (different from relative listed above)
Last Name:
*
First Name:
*
Relationship to Patient:
Select
Husband
Wife
Mother
Father
Friend
Grandparent
Other
Work Phone: (
)
-
Personal Phone: (
)
-
Patient's Substance Abuse History:
*