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MARS ATP Pre-Admission Form

To make a referral or schedule an appointment complete the online form or contact one of our locations directly.

Information entered in the form below is kept secure and confidential.

How did you find out about MARS-ATP?

Patient Information

Reason for contacting us?
Have you had prior treatment?	Yes No
Employer Name:
If Employed, how long?
Primary Care Physician (PCP):
PCP Phone Number:
Currently being treated by a physician?	Yes No
Last Exam Date:
Current Medications:	Yes No
If yes for current medications: (List name of medication, dosage, frequency, and how long)

Do you have a probation officer?	Yes No
Do You Legal Charges pending?	Yes No
Emergency Contact Name and Phone:

Insurance Information

Insurance Company:
Group Number:
ID Number:
Benefit Verification Phone Number:
Pre-Certification Phone Number:
Is patient subscriber for insurance?	Yes No
If not, who is? Name and Phone: