Contact and Insurance Information

Adultspan Counseling

Please correct the errors described below.

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.

Client Information

EXACTLY as written on insurance card
If you don't have one, type "None"

Emergency Contact (or Parent/Guardian)

Primary Insurance

Enter "Private Pay" if none.
Omit any dashes or spaces
Omit dashes, spaces - leave blank if none.
(or enter Market Place if and ACA or private plan)

Secondary Insurance (if any)

Omit dashes and spaces
Omit dashes or spaces
Or enter Market Place if an ACA or private plan

You may want to call your insurance ahead of time to find out about any policy limitations you may have including:

Insurance Card(s) and Driver's License

    Please upload a file

    Your information will be encrypted.