INSURANCE & PAYMENT OPTIONS

We are in network with many major insurance companies.
If you do not have insurance, or if we do not take your particular insurance, we also accept self-pay.

YOUR INSURANCE BENEFITS

Knowing your insurance coverage and benefits is important for understanding the potential fees prior to your appointment. We are happy to assist in verifying insurance coverage and benefits for new and established clients. We try our best to be as accurate as possible when verifying your benefits, however, your fees may change depending your eligibility and benefits.

Please note that we may not know your exact fee until we submit claims to your insurance and receive your explanation of benefits (EOB) back from your insurance company. Ultimately, you are responsible for knowing and understanding your insurance coverage.

In order for us to verify your insurance benefits, please fill out the Insurance Verification following form.
*If you have already emailed us your insurance card or provided your information via your client portal, there is no need to submit this information again.

INSURANCE VERIFICATION

SECTION 1: Demographic Information

Name

First Name

Last Name

Do you have an appointment requested/schedule?

Yes

No

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Therapy Type

Therapist

SECTION 2: Primary Insured's Information

If the individual completing this form is the primary insured, please select SELF and skip this section. If you are not the primary insured, please complete this section.

*Your relationship to the Primary Insured:

Primary Insured's Name

First Name

Last Name

Primary Insured's Date of Birth

MM

DD

YYYY

Primary Insured's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SECTION 3: Insurance Information

Select your Primary Insurance

If your insurance is not listed, please provide the name below

Insurance ID #

Group ID #

Customer Service # on the back of your card

(###)

###

####

Is this your primary and only insurance coverage?

Yes (please skip the next section)

No, I have a secondary insurance (please complete next section)

SECTION 4: Secondary Insurance Information

If you only have one insurance policy, please skip this section.

Secondary Insurance/Primary Insured's Name

First Name

Last Name

Secondary Insurance/Your relationship to the primary insured

Secondary Insurance/Primary Insured's Date of Birth

MM

DD

YYYY

Secondary Insurance/Primary Insured's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Select your secondary insurance

Secondary Insurance/Member ID #

Section 5: Additional Information

Please provide any additional information about your insurance benefits, if any:

PAYMENT

We also accept cash, check, and most major credit cards as forms of payment.

Other Questions? Feel free to contact us.

Contact Us

INSURANCE & PAYMENT OPTIONS

YOUR INSURANCE BENEFITS

PAYMENT

The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.