Documentation

Administration department and MRCI Intake works to ensure that the admission process flows as well as possible for our patients  and their families. Equally important is helping potential patients and their families to feel comfortable and knowledgeable about our services.

Required Documentation:

Patient with Medicaid or Medicare

  1. Identification
    • ​​Driver's License or
    • Other photo ID 
  2. Insurance
    • Card Insurance

Patient with No Insurance for NTBHA Program

  1. Identification
    • ​​Driver's License or
    • Other photo ID
  2. Proof of Adress
    • ​​Lease or Mortgage agreement or
    • Utility bill or 
    • Life/Auto/Homeowner's insurance
  3. Proof of Incomes
    • Unemployment award letter or
    • Letter of employment or
    • Three recent pay check stubs bi-weekly / Six check stubs if paid weekly

 

DOWNLOAD

Intake English
Form Intake English.pdf
Adobe Acrobat document [1.2 MB]
Intake Spanish
Form Intake Spanish.pdf
Adobe Acrobat document [611.3 KB]
Verification of Assistance Form - Spanish
Verification of Assistance Form - Spanis[...]
Adobe Acrobat document [261.9 KB]
Verification of Assistance Form - English
Verification of Assistance Form - Englis[...]
Adobe Acrobat document [252.8 KB]
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