Outpatient Mental Health Clinic Intake

Start the Process Today

As the need for mental health care has steadily increased in recent years, Wellpoint Care Network’s outpatient clinic has stood at the ready. We provide therapeutic support for a variety of mental health needs and accept a variety of insurance options, including Medicaid.

Wellpoint Care Network’s Outpatient Clinic is located at 8901 W. Capitol Dr. in Milwaukee, Wisconsin and is open Monday through Friday 8 a.m. to 7 p.m.

Intake Forms

Our clinicians look forward to working with you as you embark on your healthcare journey. To help speed up the intake process, please complete the fillable PDF forms below. If you have any questions, please do not hesitate to call us at 414-465-5770 or Contact Us.

Speed up the intake process by completing ONE of the following forms for the person being treated and submit the information directly from within the form prior to your first visit. Anyone under 18 will need a parent or guardian to help complete and sign their paperwork.

DOWNLOAD INTAKE FORM FOR ANYONE 18+ [PDF]
DOWNLOAD INTAKE FORM FOR ANYONE UNDER 18 [PDF]

If you have any questions, please do not hesitate to call us at 414-465-5770 or Contact Us.

The following forms provide you with helpful information about our Outpatient Clinic policies, as well as our strict adherence to HIPAA Privacy Practices. We appreciate your patience and careful review of these documents prior to signing the above forms.

DOWNLOAD NEW CLIENT INFORMATION FOR ADULTS [PDF]
DOWNLOAD NEW CLIENT INFORMATION FOR CHILDREN AND TEENS [PDF]

If you have any questions, please do not hesitate to call us at 414-465-5770 or Contact Us.

Frequently Used Forms

Below, we’ve collected the most frequently-used forms and other healthcare-related documents for your ease of access. If you are looking for something specific not listed here, please call us at 414-465-5770 or Contact Us.

Wellpoint Care Network is committed to maintaining the privacy of your Protected Health Information. This Notice explains how that information may be used and disclosed to others, effective as of June 1, 2018.
DOWNLOAD FULL NOTICE [PDF]

All individuals who have received services at Wellpoint Care Network have the right to access their medical records in accordance with DHS 51.30. To request a copy of your medical records, complete the form below and submit with a proof of identification via fax (414-260-8980), email or in-person. Requests for clients age 14-17 must contain client and parent signatures.

DOWNLOAD RECORDS REQUEST FORM [PDF]

If cost of services is preventing behavioral health treatment, Wellpoint Care Network offers Financial Assistance based on the Federal Poverty Guidelines and a sliding fee schedule.

DOWNLOAD FINANCIAL ASSISTANCE POLICY [PDF]
DOWNLOAD FINANCIAL ASSISTANCE APPLICATION [PDF]

Under the law, individuals who are not using health coverage to pay for services have the right to receive a “Good Faith Estimate” explaining how much services will cost before they are provided.

DOWNLOAD GOOD FAITH ESTIMATE POLICY EXPLANATION [PDF]
DOWNLOAD SELF PAY WAIVER AND GOOD FAITH ESTIMATE [PDF]

When you get emergency care or are treated by an out-of-network provider at an in-network care facility, you should not be charged more than your plan’s copayments, coinsurance and/or deductible.
DOWNLOAD NO SURPRISE BILLING POLICY [PDF]

Read a full list of Our Policies.

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