Prospective Patient Form

Your Information

Person Completing This Form
Name
Enter date in the YYYY-MM-DD fomat.
By entering in your telephone number, you agree to receive transactional SMS notifications and reminders from ERC and Pathlight via short code 73821. Message and data rates may apply. Message frequency may vary. You may receive alerts until you choose to opt out of this service by texting STOP to 73821 or replying STOP to any of our messages. Text HELP to 73821 for assistance.
Mailing Address

Treatment Information

Condition

Insurance Information

If you have government insurance (Medicare/Medicaid/Tricare), we first need to speak with the case manager at your insurance company. Rather than completing this form, please have your case manager contact us at 1-877-920-2902.
Learn about additional treatment options and resources that you may be eligible for here.

If you are not currently insured, please learn about additional treatment options and resources that you may be eligible for here rather than submitting this form, or call us at 877-825-8584.

Insurer
Enter date in the YYYY-MM-DD fomat.

Current Treatment Team Information

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