Health Insurance Form

Patient Information

Name*

First NameLast Name

Last Name of clinician patient is seeing at PsychCare

Insurance Information

Please note that if you do not have your new ID number yet, you should wait to complete this form as it will require the member ID.

Clinicians at PsychCare are NOT in network with United Healthcare or Kaiser. If you are insured through one of these networks, please call our office and we will be happy to chat with you about private pay rates and next steps.

Thank you.

Primary Insurance Co*

Policy No*

Group No*

Primary Insurance Phone Number for Providers (Usually Listed on Back of Card)*

Area CodePhone Number

Subscriber's Relationship to Patient*

SelfSpouseChildOther

Subscriber's Name*

First NameLast Name

Date of Birth*

Date

Do you have a Secondary Insurance*

NoYes

Secondary Insurance Co*

Policy No*

Group No*

Secondary Insurance Phone No*

Area CodePhone Number

Subscriber's Relationship to Patient*

SelfSpouseChildOther

Subscriber's Name*

First NameLast Name

Date of Birth*

Date

Do you have an upcoming appointment with your clinician in LESS than 48 business hours that you would like to begin using your new insurance ?*

NoYes

Please Note: Our office staff will need at least 48 business hours to verify new insurance information.

If the upcoming appt is within less than 48 business hours than you as the client have several options that depend on the type of insurance change:

[Universal Option] (1) Move the appointment to a new date that is at least 48 business hours out from when this form is being completed (if the appointment is within less than 24 business hours - your clinician will determine with you if a late cancellation fee will be charged)

[Non-Medicaid] (2) Agree to pay the full private pay fee for the upcoming session and once the insurance is later verified you will be refunded accordingly. (Option # 2 is NOT an option for clients changing their insurance to Medical Assistance as Medical Assistance requires an authorization that can not be back-dated)

[Only For Clients Using Insurance Until Now & Switching to EAP] - (3) Continue to see your clinician with the non-EAP insurance that you were using up until now and begin using the new EAP benefits for subsequent session (after it has been verified by our office staff)

Name

First NameLast Name

Date