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Client Contact and Insurance Verification

Client Contact and Insurance Verification

Please complete this form at least 48hrs prior to your scheduled appointment to allow sufficient time for a benefit inquiry.

Select Therapist

Client Name*

Client Address*





Client Phone Number*

Client Email*

Client Status*

Emergency Contact Person

Emergency Contact Number

Type of Health Insurance*

Insurance Provider

Insurance Contact Number (listed on back of insurance card)

Member ID Number*

Group ID Number*

Client Date of Birth*

Subscriber Name (if different from client)

Subscriber Date of Birth (if applicable)

Deductible Amount (if known)

Co-Pay/Coinsurance Amount (if known)

Click on the icon below to make a secured online payment

paypal

Full fee is $125 to $175 per session. We are currently in-network with BCBS and United/Optum insurance.  We take other forms of insurance out-of-network.  We also accept Medicare.

Note: Cancellation policy is 24 hours in advance to void responsibility for payment.