Health Insurance

CMHS

Comprehensive Mental Health Services was founded in 1988. Since the beginning our plan has been to combine the personal attention of a private practice with the strength of a larger organization. Accordingly, we employ a broad range of clinicians, we offer a wide range of services and - within the practice - we contribute to one another's work.

As a courtesy to you, Comprehensive Mental Health Services (CMHS) can submit insurance claims on your behalf. At CMHS, we hope this will make it easier and faster for you to receive insurance reimbursement. In order to do so, we require the policyholder's information and the patient's/client's consent, found below.

Please know we do not have the staff to track whether insurance claims actually go through, or whether they are paid as anticipated. Accordingly, it is your responsibility, exclusively, to detect and manage any difficulties that may arise.

I consent to let CMHS share my protected healthcare information with my insurance carrier for purposes of billing and reimbursement, and I expect the policyholder to receive the latter directly. I will pay CMHS for and at the time same time of service.

Policyholder Information

Name of Policyholder

Date of Birth

Relationship to Patient

Effective Date of Policy

Identification Number

Group Number

Policyholder's Mailing Address

City

State

Zip Code

Primary Insurance Company

Insurance Company's Mailing Address

City

State

Zip Code

Your information will be encrypted.