Ortiz Wellness Center | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Address

Reason for care

What is the reason for seeking care?

What type of care are you looking for?

What mental health concerns or treatment have occurred in the past?

Administrative

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How do you plan to pay?

Primary Insurance

Primary insurance in healthcare is the plan responsible for paying medical claims first, covering the largest portion of costs up to its policy limits before any other insurance (secondary) is billed. It acts as the main coverage for services, such as employer-provided plans, and is determined by specific coordination of benefits rules.

Insurance card upload

Upload a photo of your insurance card

Member ID

Group ID

Secondary Insurance

Secondary medical insurance is an extra policy that covers healthcare costs not paid by your primary insurance, such as deductibles, copayments, and coinsurance. It helps lower your out-of-pocket expenses through a process called "coordination of benefits," where the primary insurance pays first, and the secondary insurance covers the remaining approved amount. If you select "Yes," an Intake staff member will contact you to collect the necessary information.

Yes No

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Inquiry reason

Preferred Location

Choose one of our locations.

Language Preference

We offer convenient services in Spanish and English, Select one:

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.