Please list all applicable health insurance policies that you have. Please list them in the order of responsibility (i.e., primary coverage should be listed first, then secondary, etc.) Incorrect or missing coverage information may result in claim delays or rejections.
(Please list all known medical conditions as well as who in the family is affected)
Thanks for trusting us to help you! If at any point you have any questions or concerns about the treatment you receive, please let your therapist know.
Your information will be encrypted.