Contact — Cleveland Health and Wellness Center

Patient's Name

First Name

Last Name

Preferred Name (how would you like us to refer to you?)

Phone

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Date of Birth (month/day/year)

Home Address (Street/City/State/Zip)

If you would like to use insurance, which insurance plan do you have? (e.g. Aetna)

Do you have any other insurance coverage? If so, what is it?

What is the Member ID number listed on your insurance card?

Are you the primary person listed on your card?

What is the full name, date of birth, phone number, and address of the primary insured?

What is the Provider Phone Number listed on your insurance card?

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Parent/Guardian's Name (for minors)

First Name

Last Name

Message

The following insurance is accepted for Psychiatry:

*Eileen Zehe, NP is in-network with Anthem Blue Cross Blue Shield, Dr. Bonder is out of network.