Tranquility Behavioral Health Patient Portal - Publicforms

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Available Forms

2025 FINANCIAL POLICY AND TERMS OF PAYMENT 2025 TREATMENT AND CONSENT FORMS 2025 ID SUBMISSION 2025 INSURANCE Card Submission 2025 KHHWC General Consent 2025 MEDICAL RECORDS/PAPERWORK REQUEST 2025 NEUROCOGNITIVE CONSENT FORM 2025 NEW PT Patient Questionnaires 2025 NURSE MESSAGE FORM 2025 Prescription Refill Request 2025 TBHC NEW PATIENT REQUEST FORM 2025 TRANQUILITY360 MIND+LIFE PSYCHOEDUCATION PROGRAM Appointment Cancellation Request MEDICATION REFILL REQUEST

2025 INSURANCE Card Submission

Tranquility Behavioral Health Insurance Card & ID Submission Form

DATE: *

Patient First & Last Name *

Phone Number *

DOB *

PROVIDER *

Dr. Henrietta Evans, DNP, RN PMHNP-BC, GNP-BC

Dr. DoNesha Tinsley, DNP, PMHNP

Insurance Provider *

Member ID Number *

Group number (if applicable)

Upload Insurance ID *

* Required field