Frank Chen, MD, PA
Brainflo, PA - Florence Kim, MD
Michael Barber, MD, PA
© 2011 Frank Chen, MD, PA
New Patient Request
The following information will be asked when setting up a new
patient appointment. We encourage you to provide as much
information through this form as you feel comfortable. The use of
this form will reduce your time on the phone and will reduce data
entry errors. Information will be transmitted in real-time. We will
contact you by phone within the same business day. Alternatively,
you can call our scheduling coordinator after submitting your
information. We will confirm all information and gather missing
information by phone.  Please have your insurance card available
to complete the appointment scheduling.

Please note that all messages left after hours or on weekends
will be checked on the following business day.
Provider Request:
Referral source:
Patient's last name:
Patient's first name:
Patient's middle name:
Patient's address (line 1):
Patient's address (line 2):
Patient's city:
Patient's state:
Patient's zip code:
Patient's primary phone
number:
Patient's secondary
phone number:
Patient's email:
Insurance company:
Mental health carrier: (if
available) (back of card)
Policy Number:
Group Number:
Policy holder's employer:
Policy holder's full name:
(if different from patient)
Policy holder's date of
birth: (if different from patient)
Policy holder's ssn: (if
different from patient)
Benefits verification
phone number:
Mental health phone
number: (if available)
Patient's social security
number:
Patient's date of birth:
Patient's sex:
Patient's marital status:
Comments/ Requests/ Additional Information (optional):
Some insurance
companies contract
other companies to
handle mental
health benefits. You
can locate mental
health carrier phone
numbers on the
backside of your
card.
Mental health
insurance coverage
can be confusing.
You have the option
of faxing the front
and back of your
insurance card to us
at 832-384-1585 to
facilitate scheduling.
2180 North Loop West
Suite 450
Houston, TX 77018
Ph: 832-384-1560
Fax: 832-384-1585