Prospective Patient Form

Our admissions process begins with a comprehensive assessment of each patient’s medical, psychological and sociocultural history, as well as thorough verification of insurance benefits. Together with guidance from the Clinical Assessment team, this information helps patients and families make informed decisions about pursuing and financing eating disorder treatment.

Please complete the form below to provide your information to our Clinical Assessment team. By submitting this information, you are consenting to have a clinical team member follow up with you as well as have our business office check your insurance benefits.

Prospective Patient Form

Your Information

Person Completing This Form

First Name

Last Name

First Name

Last Name

Date of Birth

Enter date in MM/DD/YYYY format.

Best Phone

Phone Type

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.

Address

City/Town

State

ZIP Code

Preferred Method of Contact

Is there a method we cannot use?

Patient Information

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Enter date in MM/DD/YYYY format.

Treatment Information

Location of Interest

Desired level of care

Condition

Insurance Information

Type of Insurance

Please be advised that treatment coverage under Medicaid requires a Single Case Agreement (SCA). This is a special contract negotiated between ERC Pathlight and Medicaid for your specific treatment. While ERC Pathlight initiates this process on behalf of the patient, approval is determined by Medicaid.

We are in the process of increasing our ability to accept Medicaid, Managed Medicaid, Medicare, Medicare Advantage, VA or Tricare) plans.
We currently are able to accept Patients with Tricare West who reside in Colorado, California, or Washington
At this time, we are able to accept Single Case Agreements* (SCA) with the following plans:

Patients with Medicaid seeking care in California, Colorado, Ohio or Washington
* Single Case Agreement (SCA): This is a special contract negotiated between ERC Pathlight and Medicaid for your specific treatment. While ERC Pathlight initiates this process on behalf of the patient, approval is determined by Medicaid.

If you have these plans, please call us at 303-825-8595 to discuss the admissions process, or select the appropriate option from the list above. If you do not meet these exceptions, please contact your insurance company for assistance with seeking care at an in-network facility. Explore additional treatment options and resources that may be right for you on our insurance page.

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 866-360-7449.

Insurer

Insurance Contact Phone Number

ID/Account Number

Group Number/Account Number

Name of Policyholder

Relationship to Patient

Policyholder Date of Birth

Enter date in MM/DD/YYYY format.

Name of Policyholder's Employer

To whom do you want to communicate insurance information

Name

Phone

Current Treatment Team Information

Therapist Name

Family Therapist

Psychiatrist

Primary Care Physician

Other Outpatient Team Members

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