Language
  • English (US)
  • HEALTH INSURANCE & PAYMENT AGREEMENT FORM

    (you will need a front and back copy of your insurance card)
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    Pick a Date
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  • SERVICES REQUESTED

    (Submit your insurance requests at least 4 weeks before your estimate start of care date for priority consideration.)

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    Pick a Date
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  • Health Insurance Plan Type

  • Primary Insurance Information

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    Pick a Date


  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Secondary Insurance Information

    (if applicable)
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  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Additional Information

    (Please include any additional information that you feel will help CNS staff in verifying your insurance benefits.)
  • Terms and Conditions

  • I authorize the release of any medical or other information necessary to process an insurance claim. I understand that CNS will diligently attempt to get accurate information regarding my health insurance benefits. I will not hold CNS liable for insurance nonpayment due to misquoted benefits. I acknowledge that I am responsible to know and understand my benefits plan. If CNS accepts me as a client, then CNS will file my insurance claims if in-network for me as a courtesy. I am ultimately responsible for any co-pay(s) and all charges my insurance company does not pay, except for contracted network provider discounts that may apply. I also request assigned benefits be paid to CNS.

  • Clear
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  • Should be Empty:
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