For Patients

Please complete the form below in its entirety to have your insurance benefits verified prior to your first appointment.  If you are a current patient updating your coverage info, please indicate the effective date of the new policy in the Comments section at the bottom of the form.

Doctor/Therapist Being Seen

Appointment Date

Patient Name

Patient Date of Birth

Full Address

City, State, Zip


Insurance Carrier

Member/Subscriber ID

Group Number

Name of Insured - if other than patient

Insured's Date of Birth

Insured's Employer

Mental/Behavioral Health phone number on card (if present)

Customer/Member Service Phone number on card

Name of Individual Completing Form

Your Email

Comments/Special Instructions: (Use this space to provide EAP details, indicate if the appointment is pertaining to testing or a surgical procedure, effective date for new plans, etc.)

Note: If you have a secondary insurance carrier, please submit an additional form and indicate that it is secondary coverage in the Comments section.