Solvista Registration form V5 revised 7.2025

REGISTRATION FORM
If you need any help filling out this form, please contact us at (719) 275-2351
CLIENT INFORMATION
Client Name*
Preferred Name
Pronoun(s):

HeSheTheyOther
Social Security #:
Birth Date*

MonthDayYear
Assigned Gender for insurance and legal purposes:*

MaleFemale
Gender Identity:

MaleFemaleTransgender (ftm)Transgender (mtf)GenderqueerOtherPrefer not to answer
Are you the client?*

YesNo
Are you the Biological Parent?*

YesNo
Are you the Legal Guardian?*

YesNo
(Parent/Guardian Name if client is under 18) Name:*
Physical Address:*

Physical Address

Street Address Line 2

CityState

Zip
Is Physical address same as Mailing Address?*

YesNo
Mailing Address (if different from Physical address)*

Mailing Address

Street Address Line 2

CityState

Zip
Primary phone #*
Primary Phone #

LandlineCell Phone
Secondary phone #:
Please enter a valid phone number.
Secondary Phone #

LandlineCell Phone
Is it okay to leave a message on the primary contact number?*

YesNo
Appointment Reminder Message Type:

Phone callText (Cell Phone only)
Appointment preference:*

TelehealthIn PersonNo Preference
Email Address
example@example.com
Do you have a primary care provider?*

YesNo
If so, please provide doctor's name:
Are you being referred by any of the following? Please mark all that apply and provide contact name:*

Family:Medical Physican:Friend:Probation:DHS:Self:School:Hospital:Other
Employment Status:*

DisabledFull-Time JobPart-Time JobActive-Duty MilitaryRetiredStudentVolunteerUnemployedHomemakerSupported Employment
Marital Status:*

NeverMarriedDivorcedMarriedMarried,SeparatedWidowed
Primary Language*
Do you need an interpreter?

YesNo
Ethnic Origin:*

CubanMexican/Mexican AmericanPuerto RicanOther HispanicNot Hispanic/LatinoPrefer not to answer
Race (check all that apply):*

American Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderBlack or African AmericanWhite/CaucasianPrefer not to answer
Sexual Orientation:

BisexualGay/LesbianStraight/HeterosexualOtherDecline/Prefer not to answer
Are you Pregnant?*

YesNo
Highest Level of Education Completed:*

Grade schoolMiddle schoolHigh school/GEDCollege/University
Tobacco Use Status:*

Current every dayCurrent some daysFormer SmokerHeavy SmokerLight SmokerNever Smoked
Living in your home (mark all that apply):*

AloneChildrenFatherFoster ParentGuardianPartner/Significant OtherMotherSibling(s)SpouseRelatives (kin)Unrelated Person
Homeless:*

YesNo
Have you ever served in the U.S. Military?*

YesNo
Do you have an Advance Directive/Living Will?*

YesNo
Emergency Contact
Name:
Relationship
Is the address the same as the client?

YesNo
Address:

Physical Address

Street Address Line 2

CityState

Zip
Home phone #
Cell phone #
INSURANCE INFORMATION:
Is the client covered by insurance?*

YesNo
Policy Holder name*
Birthdate*

MonthDayYear
Date
Policy Holder SSN:
Relationship to Policy holder:*

SelfSpouseChildOther
Name of primary insurance (if applicable):*
Policy Number/Member ID:*
Group Number:*
Name of secondary Insurance (if applicable):
Policy Number/Member ID:
Group Number:
Is the Policy holder address the same as the client?*

YesNo
Address if different from client
Home phone
PAYMENT INFORMATION:
Annual Income of total household:*
Source:*

Not SSI/SSDISupplemental Security IncomeSocial Security Disability
Additional Income:
Source:

Not SSI/SSDISupplemental Security IncomeSocial Security Disability
Total number of family members supported:*
How many dependent children does the CLIENT have?*
Proof of income: *

Paystubs, award letters, taxes, Court Decree, etc
Cancelof
I verify, by signing below, that the income noted is my verifiable household income and number of dependents. I may be asked to provide proof of income or benefits. I authorize my insurance benefits to be paid directly to the physician. | understand that | am financially responsible for any balance. I also authorize Solvista Health or insurance company to release any information required to process my claims. Falsification of information may result in disqualification of assistance.
Client/Parent/Guardian Signature*

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Date*

MonthDayYear
Date
Should be Empty:

REGISTRATION FORM

CLIENT INFORMATION