INSURANCE VERIFICATION

If you would like us to verify your insurance, please complete our form here:

SECTION 1: Demographic Information

Name

First Name

Last Name

Do you have an appointment requested/schedule?

Yes

Date of Birth

YYYY

Phone

(###)

###

####

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

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

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:

OR, you can e-mail us a copy/picture of your insurance card and your drivers license prior to your first session.

Note: if you are not the primary insured/policy holder, please include the full name, date of birth, address, and the relationship to the primary insured (i.e. parent, spouse, other).

E: info@borghicounseling.com

INSURANCE VERIFICATION

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