Insurance Verification Form

Insurance Verification Form

Thank you for reaching out about your insurance coverage! To allow our team to contact your insurance company to verify your benefits, please fill out the form below.
Please understand that insurance companies sometimes misquote benefits, so benefit checks by Twin Lakes Counseling are not guaranteed in accuracy. It is important that you check your own mental health benefits as well by calling your insurance company directly. In the event that a benefit is misquoted, it is still your responsibility to pay your balance.
Client Information
Client's Name*

First NameLast Name
Client's Email*
example@example.com
Has the client been scheduled with Twin Lakes Counseling?*

YesNot yet
Clinician
Email of requester (if different from above)
example@example.com
Client's Date of Birth*

MonthDayYear
Date
Interested in medication management services?

YesNo
Do you have prescription insurance?

YesNo
Primary Insurance Information
Is the client on someone else's insurance?*

YesNo
Insurance Company*
Member Number (including prefix)*
Insurance Phone Number

Area CodePhone Number
Subscriber's Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Relationship to Patient
Please note that if the client is not the subscriber, the subscriber's address, date of birth, and phone number are required to verify the insurance and submit claims.
Subscriber's Phone Number

Area CodePhone Number
Subscriber's Address

Subscriber Street Address

Subscriber Street Address Line 2

Subscriber CitySubscriber State / Province

Subscriber Postal / Zip Code
Do you have a secondary insurance?*

YesNo
If you have a secondary insurance and do not disclose it to us, your clinician may not be able to accept your insurance at all, which risks you being responsible for the full cost of treatment and/or having to be discharged from treatment prematurely.

Please note that at this time Twin Lakes Counseling is unable to submit claims to secondary insurances unless one of the insurances is Medicaid. After services commence, you are always welcome to submit superbills to your secondary insurance to receive any reimbursement to which you are entitled.

If you have secondary insurance, we ask you to immediately reach out to your primary insurance to arrange the Coordination of Benefits. Please also upload pictures of the front and back of your secondary insurance card below as well.
Please upload pictures of the front and back of ALL your insurance card(s). If you have difficulty with the submission process, you may also email them to billing@twinlakescounseling.com.*

Browse Files

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Is there anything else about your insurance we should know?
Should be Empty: