Insurance Verification Request

Insurance Verification Request
Directions:
You may use your phone, tablet, or computer to complete this form.

To get started, you'll need your insurance card and photo ID. Once you've finished filling out the form, you'll need to take photos of both cards and upload them before you submit. When you have your insurance card and ID in hand, click Next to continue.

Contact Information
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Phone:*
Who's your doctor/therapist/provider?*
If you haven't spoke to a provider yet or if yours isn’t listed, select 'Not Sure'
Which of the following applies?*

I want in person appointmentsI prefer Telehealth (over video)I'm open to either in person or telehealth

Insurance Information
Each provider has different circumstances when it comes to insurance. Some don’t accept insurance, some accept a few plans, and some accept many.

We have a limited number of providers who are fully credentialed with insurance. This means if you wish to utilize your insurance, you may be added to a wait list until one of our providers has an opening for an insurance-based client. The wait could be a month or longer. If you are in a crisis or need urgent care, we recommend paying out-of-pocket until we have an opening or seek out other in-network providers in your area.
Insurer:*
Mednes Health is contracted with these insurers only. If yours isn't listed, select 'Other' and provide further details in the Comments section below. If your preferred provider is not contracted with your plan, we will inform you and present others who can accept your insurance.
ID Number:*
Insurance card issue date:

MonthDayYear
If known
Date of Birth:*

MonthDayYear
Attach a copy of your insurance ID Card.*

Cancelof
Attach a copy of your state issued DL / ID card.*

Cancelof
Do you receive health insurance through Medicaid / Medi-Cal?*

YesNo
Since you're a Medicaid / Medi-Cal beneficiary, we need the number on your state issued BIC (Benefits Identification Card), too. If you don't have the card handy, please enter your Social Security Number (SSN) so that we can accurately process your claim. *

Submission of this form will authorize Medens Health to verify your mental health eligibility and benefits, including any copay and deductible. Results are typically available within one to two business days.

If you have any questions contact your provider or send us a message at hello@medenshealth.com.
Comments:
Date*

MonthDayYear
*

Clear
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