Please print page and mail the filled out form to the above address.
This is to help us both be aware of your insurance plan and their requirements for your care. Please be sure to contact your insurance representative to get answers to the following questions.
Name of INSURANCE CARRIER:____________________________________________
Insurance phone number found on the back of your card:______________________________
Insurance I.D. Number____________________________
Employer_______________________________________
Group Number_________________________________
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Am I listed in their data base as an "in-network" provider _________? Authorization Number from insurance company_______________________________ Number of sessions authorized ___________________________ Insurance requirements for treatment plan submissions including fax numbers/or mailing addresses ________________________________________________ ________________________________________________ Your benefit including number of sessions per calendar year _________________________ Your co-payment due at the completion of the session _____________________________ Mailing address for the submission of bills ____________________________________________________ Does your plan require payment of a deductible for mental health treatment?____________ Has your deductible been met for the year ?_________________ Is there a new deductible each year?_________ Please let me know if you change insurance plans at any point in the course of therapy. I understand it is my responsibility to be knowledgeable and informed about my insurance benefit and agree to that responsibility. Client Signature: ____________________________ Date: _____/______/_____
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