Home Client Contact and Insurance Verification

Client Contact and Insurance Verification

by Jake Colton

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


    The out-of-pocket fee is $175 per 45 minute session. We are currently in-network with BCBS, and Medicare.  We take other forms of insurance out-of-network.

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