Contact and Insurance Information

Be sure to have your insurance card and drivers license before starting this form and have a picture on this device to be able to upload pictures of each. The information in this form will be securely transmitted to Adultspan and uploaded to your electronic health record and viewable only by clinicians and billing staff.

What therapist are you completing this form for?

Client Information

First name

EXACTLY as written on insurance card

Last name

Phone number

Email address

If you don't have one, type "None"

Date of birth

Patient's Preferred Name

Address

Emergency Contact (or Parent/Guardian)

First name

Last name

Phone number

Email address

Parent/Guardian/Emergency address if different from above

Name, Street, City, State and Zip

Primary Insurance

Insurance company

Enter "Private Pay" if none.

Name of Insured EXACTLY as written on card

Insured's Date of Birth

Member ID

Omit any dashes or spaces

Group ID (if any)

Omit dashes, spaces - leave blank if none.

Employer

(or enter Market Place if and ACA or private plan)

Insured's Address (If different from above).

Name, Street, City, State, Zip

Patient/Guardian authorizes AdultSpan PC to release of information for transactions and assignment of benefits for claims

Secondary Insurance (if any)

Secondary Insurance Co.

Name of Insured EXACTLY as on card

Insured's Date of Birth

Member ID

Omit dashes and spaces

Group ID (if any)

Omit dashes or spaces

Employer

Or enter Market Place if an ACA or private plan

Insured's Address (if different from patient)

Name, Street, City, State and Zip

Patient/Guardian authorizes AdultSpan PC to release of information for transactions and assignment of benefits for claims

Call your insurance to find out about any policy limitations including:

Is telehealth a covered service? Some times insurance doesn't cover it, requires a specific platform, or must be 60 min or more from a clinician.

Yes No With Limitations

Is Marriage Counseling excluded as part of billing code 90847 At times "Marriage Counseling" isn't considered medically necessary.

Yes No Not applicable

Do hour session (billing code 90837) require preauthorization? Please be aware that Optum, UHC, UBH, UMR and Mediciad may limit your clinicians use of 60 minute session and require 45 minute sessions.

Yes No Not sure

What is my copay/coinsurance for non-specialist office visit?

What do I have left on my deductible to pay before insurance starts?

Insurance Card(s) and Driver's License

Attach a photo of your drivers license and insurance card here (or bring to your first session)

Add file

Please upload a file

Today's date

Your information will be encrypted.