Bowen Center Pre-Registration Form

Attempts will be made to contact you on the days and times specified. PLEASE ALSO NOTE THAT WHEN YOU ARE CONTACTED, SOMEONE FROM OUR ACCESS DEPARTMENT WILL BE GOING OVER THE INFORMATION YOU PROVIDE HERE FOR THE PURPOSE OF VERIFICATION. Please allow two business days for a response to your request to schedule an appointment. If information is submitted on a weekend, it will be processed on the next business day.

IF YOU ARE EXPERIENCING AN EMERGENCY, PLEASE CALL 911, VISIT YOUR LOCAL EMERGENCY ROOM OR CALL 1.800.342.5653 TO CONTACT A LIVE PERSON

* Indicates required field

mm/dd/yyyy
Street Address or P.O. Box
XXX-XXX-XXXX
* Select method of payment. NOTE: For applicants who select self pay, please move on to appointment information. For all others, fill out fields under the appropriate method of payment. THIS SECTION IS REQUIRED



MEDICAID (Hoosier Health Wise/HIP)

Enter names as they appear on the card
Once ID number is entered, proceed on to appointment section

MEDICARE

Enter names as they appear on the card
Once ID number is entered, proceed on to appointment section

PRIVATE INSURANCE

Please enter the information regarding the insurance plan:

Policy holder's relationship to person being registered



POLICY HOLDER INFORMATION
mm/dd/yyyy
XXX-XXX-XXXX
xxx-xxx-xxxx
xxx-xxx-xxxx

APPOINTMENT INFORMATION

Limit to 1500 characters
Friday options 8 a.m. to 4:45 p.m.
xxx-xxx-xxxx