Insurance Verification Form

I would like to use insurance for my counseling services and I have Aetna, Anthem/Blue Coss/ Blue Shield, Beacon Health Options, Cigna, Humana, Tricare or Wellcare insurance coverage

I would like to use private pay and agree to the $100 hourly cost per session

To verify your insurance coverage and confirm your copay amount; please answer the following questions:

Insurance Company:

Patient Name:

Date Of Birth

Insurance Company Phone Number:

Insurance ID#

Home Address:

Name and Date of Birth of Main Insured:

Email address

Your information will be encrypted.