Patient Assistance

Streamline your routine needs.

We are dedicated to making access and assistance to routine patient needs simple and straightforward. We also value being organized so we do not miss opportunities to serve.

To achieve this, we ask that you fill out our secure, HIPAA compliant patient request form for some of our most common patient needs.

Carencia Patient Assistance Form
Get User IP
Welcome to the Carencia Patient Assistance process where you can make appointment changes, check-in for your appointment, request various forms and update your information.
Patient Request
Please select an option below as the reason for your request.
Billing Information Update
If you have a known balance, need to make a payment, or update your payment information please contact Carencia's BillingTeam at billing@carencia.com and someone from our care team will reach out to assist.

Please note all calls come from our office number, (682) 478-5333 and we recommend saving this as a contact in your phone so that you can easily identify calls from the Carencia team.
Would you like to specify a convenient time for a member of our Care Team to reach out to you?*

YesNo

Appointment Check-In
Appointment Type*
Please Select a Provider*
Scheduling Acknowledgement*

I understand that Carencia expects payment of patient responsibilities at the time of visitI understand that Carencia expects payment of patient balances before any pending visits are scheduled.
Any Changes to Your Information (Contact, Insurance, Pharmacy, Medications, etc...)?*

YesNo
Patient Information
Would you like to update your basic information (Phone, Address, Nickname, Gender, Marital Status)?*

YesNo
Mobile Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Nickname
Gender*
Marital Status*
Would you like to update or provide a photo for your patient portal?*

YesNo
Please Upload a Photo of Yourself or Take a Photo On Your Device And Then Upload*

*If you receive a file size limit warning, please try cropping your image or an online image resizing tool like https://www.wix.com/tools/image-resizer and set the percentage to 25-50%.
Cancelof
Any changes to other contact methods?*

YesNo
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Any changes to emergency contacts?*

YesNo
Name*
Relation*
Phone Number*
Please enter a valid phone number.
Any changes to insurance?*

YesNo
Patient Insurance
Do you have a new insurance policy?*

YesNo
Is this for Primary, Secondary or Both coverage?*

PrimarySecondaryBoth
Do you have a primary policy that is no longer active?*

YesNo
When was the last day your previous primary policy was active?*

MonthDayYear
Date
When was the date your new primary policy was active?*

MonthDayYear
Date
Move to Self Pay Acknowledgement*

I understand that by no longer having an active insurance plan that Carencia will update my billing to self pay.
Primary Insurance Company Name*
Primary Insurance Company Plan*
Primary Insurance ID Number*
Primary Insurance Group Number*
Please upload a photo of your insurance card (front) or take a photo with your device and upload*

*If you receive a file size limit warning, please try cropping your image or an online image resizing tool like https://www.wix.com/tools/image-resizer and set the percentage to 25-50%.
Cancelof
Please upload a photo of your insurance card (back) or take a photo with your device and upload*

*If you receive a file size limit warning, please try cropping your image or an online image resizing tool like https://www.wix.com/tools/image-resizer and set the percentage to 25-50%.
Cancelof
Are you the primary insurance subscriber?*

YesNo
Primary Insurance Subscriber Name*

First NameLast Name
Primary Insurance Subscriber Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Insurance Subscriber Date of Birth*

MonthDayYear
Primary Insurance Subscriber Employer*
Primary Insurance Relationship to Subscriber*
Do you have a secondary policy that is no longer active?*

YesNo
When was the last day your previous secondary policy was active?*

MonthDayYear
Date
When was the date your new secondary policy was active?*

MonthDayYear
Date
Secondary Insurance Company Name*
Secondary Insurance Company Plan*
Secondary Insurance ID Number*
Secondary Insurance Group Number*
Please upload a photo of your insurance card (front) or take a photo with your device and upload*

*If you receive a file size limit warning, please try cropping your image or an online image resizing tool like https://www.wix.com/tools/image-resizer and set the percentage to 25-50%.
Cancelof
Please upload a photo of your insurance card (back) or take a photo with your device and upload*

*If you receive a file size limit warning, please try cropping your image or an online image resizing tool like https://www.wix.com/tools/image-resizer and set the percentage to 25-50%.
Cancelof
Are you the secondary insurance subscriber?*

YesNo
Secondary Insurance Subscriber Name*

First NameLast Name
Secondary Insurance Subscriber Address*

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Insurance Subscriber Date of Birth*

MonthDayYear
Secondary Insurance Subscriber Employer*
Secondary Insurance Relation to Subscriber*
Any Changes to Medications?*

YesNo
Medications
Medication Changes*
Any Changes to Drug Allergies?*

YesNo
Drug Allergies
Drug Allergy Changes*
Medication Refill Request
Required Medication Refill Acknowledgement*

I acknowledge that Carencia does not respond to most pharmacy refill requests. This form is required for refill requests to be processed for you.
Required Medication Refill for Controlled Substances Acknowledgement*

I acknowledge that Carencia does not refill controlled substances early without a visit.
Do you need to schedule an appointment for this refill request to be fullfilled?*

YesNo
MEDICATION(S)*
Any changes to your pharmacy?*

YesNo
Pharmacy
Pharmacy Name*
Pharmacy Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
Appointment Scheduling
Scheduling Options*
Cancellation Policy Acknowledgement*

I understand and acknowledge that if I am cancelling within 24 hours of my appointment that I will be charged a late cancellation fee according to the Appointment Agreement
Cancellation Reason*
Other Reason for Cancellation*
Would you like to schedule a new appointment?*

YesNo
Reschedule Reason*
Other Reason for Rescheduling*
Please select your preferences for scheduling a new appointment and a member of our CareTeam staff will contact you to confirm the appointment date/time.
Preferred Provider*
Are you interested in in-Person or Virtual Visits?*
Would you like the first available appointment?*

Yes, I would like the first available appointment regardless of the day/timeNo, I would like to select my preferred day/time

Additional Details for Appointment Preference
If your preferred provider does not have any openings that matches your scheduling preferences, would you. be interested in seeing another Carencia Provider for this visit?*

Yes, I would be interested in seeing another Carencia providerNo, I would like to see my preferred Carencia provider
Scheduling Acknowledgement*

I understand that Carencia expects payment of patient responsibilities at the time of visitI understand that Carencia expects payment of patient balances before any pending visits are scheduled.
If you have a known balance, need to make a payment, or update your payment information please contact Carencia's BillingTeam at billing@carencia.com
Appointment Excuse Letter
Are you requesting an appointment excuse letter for yourself or on behalf of another individual?*

This request is for myselfThis request is for another individual who I am legally authorized to represent or receive information for
Representative Full Name*

First NameLast Name
Representative Phone Number*
Please enter a valid phone number.
Relationship to Patient*
Appointment Date*

MonthDayYear
Date
Please Select A Provider*
Patient Details
Please enter your name, date of birth and email address or if filling out this form on behalf of someone please enter the patient's name, date of birth and email address to recieve the confirmation to.

Note - Its important to that your name and date of birth match to what we have on file so the form is saved to your chart.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Email*
example@example.com
Acknowledgements
Financial Agreement*

I have read and agree to Carencia’s Financial Agreement in it’s entirety.
Consent to Treatment*

I have read and agree to Carenica's Consent to Treatment in its entirety.
Communications Agreement*

I have read and agree to Carenica's Communication Agreement in its entirety.
Medication Consent Agreement*

I have read and agree to Carenica's Medication Consent Agreement in its entirety.
Appointment Agreement*

I have read and agree to Carenica's Appointment Agreement in its entirety.
Privacy Practices*

I have read and agree to Carenica's Privacy Practices in its entirety.
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Mind

Specialty Services

Body

Lifestyle

Patient Assistance

Streamline your routine needs.

Carencia Patient Assistance Form

Patient Request

Billing Information Update

Appointment Check-In

Patient Information

Patient Insurance

Medications

Drug Allergies

Medication Refill Request

Pharmacy

Appointment Scheduling

Appointment Excuse Letter

Patient Details

Acknowledgements

Complete wellness is within reach.
Let’s find your path to empowerment.

Let's stay in touch.

Mind

Specialty Services

Body

Lifestyle

Patient Assistance

Streamline your routine needs.

Carencia Patient Assistance Form

Patient Request

Billing Information Update

Appointment Check-In

Patient Information

Patient Insurance

Medications

Drug Allergies

Medication Refill Request

Pharmacy

Appointment Scheduling

Appointment Excuse Letter

Patient Details

Acknowledgements

Complete wellness is within reach. Let’s find your path to empowerment.

Let's stay in touch.

Complete wellness is within reach.
Let’s find your path to empowerment.