Florida Oasis — Patient Intake

Thank you for reaching out to Florida Oasis. Please fill out the form below so we can begin checking your insurance benefits. Someone from our team will be in touch shortly.

Patient Information

First Name *

Last Name *

📋 If you are calling on behalf of someone else, please update the name above to the patient's name, not the insurance card holder.

Date of Birth *

Phone Number *

Insurance Information

Front of Card *

📷

Upload Photo

Tap to select

Back of Card

📷

Upload Photo

Optional

Insurance Carrier *

Member ID *

Group Number

Does your card say Medicare or Medicaid anywhere on it?

✅

Thank You!

We've received your information and will begin checking your insurance benefits right away.

A member of our team will reach out to you shortly.

Florida Oasis Mental Health Center
(561) 249-1174