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

    If other please specify

    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

    The out-of-pocket fee is $150 to $200 per 45 minute session. We are currently in-network with BCBS PPO.  We take other forms of insurance out-of-network.

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