Client Contact and Insurance Verification Form

Please let us know who referred you to us?* This field is required.Please indicate below how we became known to you or referred.

Aetna

Cigna

BCBS/CareFirst

Beacon

Magellan

MD (Maryland) Medicaid

Optum (United Health Care)

Therapy for Black Girls

Therapy for Black Men

Psychology Today

Maryland Center of Excellence on Problem Gambling

Referred by friend/family/current or past client

Search Engine: Google/Bing/Yahoo!/Ask.com/DuckDuckGo

Social Media

Other

Client Full Name* This field is required.Please provide client full name, requesting service

First Name

Middle Initial

Last Name

Client DOB* This field is required.Please enter client day of birth

Date

Email Address* This field is required.Email address must be verified to continue. A verification code will be sent to this email address. NOTE: Check Spam/Junk folder if not seen in your Inbox.

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

Home Address* This field is required.Enter your current residential address.

Street Address

Street Address Line 2

City

State

Zip Code

Country

Mobile Phone Number* This field is required.Please provide mobile phone number.

Do you have a Home Phone number?* This field is required.If mobile and home phone number are the same, select "NO".

YESNO

Home Phone NumberPlease provide home phone number.

Preferred Contact MethodIndicated your preferred method to be contacted, if needed.

Home Phone

Mobile Phone

Marital Status* This field is required.Please indicated your current marital status.

Single

Married, living together

Divorced

Married, not living together

Widowed

Cohabiting with Partner

Separated

Other

Employment/Student Status* This field is required.Check each status that applies.

Employed, Full Time

Employed, Part Time

Self-Employed

Unemployed, looking for work

Unemployed, not looking for work

Disability (Social Security/Gov’t Program/Assistance Disability)

Student, Full Time

Student, Part Time

Medical Insurance Eligibility Verification* This field is required.Please select which method of payment will be used to cover this service.

Medical Insurance/Employee Assistance Plan (EAP)

No Insurance/Self-Pay

Medical Insurance/Employee Assistance Plan (EAP) Eligibility Verification

Before treatment can begin, as a courtesy, we will contact your insurance company to verify eligibility and determine if prior authorization is needed for treatment. We cannot guarantee that our services will be covered 100% by your insurance. Therefore, we recommend you contact your insurance company directly for details of your specific plan's limitations, exclusions, and benefits.

To verify your identity and medical insurance eligibility benefits. Please provide a copy of the patient's state-provided driver's license or identification card, medical information ID card for self or the patient's responsible party, or the authorized representative. All information must be current and up-to-date.

Medical Card - Image Front and Back* This field is required.Smartphone/Computer: Take a picture or upload file/image of front and back of Medical ID Card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Support file type: pdf, doc, docx, rtf, jpg, jpeg, png, and gif

Medical Card - ID and Group Information* This field is required.Please provide client Medical Card ID and Group/Benefit numbers needed for verification.

ID No.

Group/Benefits No.

Driver License - Image Front and Back* This field is required.Smartphone/Computer: Take a picture or upload file/image of front and back of state-issued Driver License or Identification Card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Support file type: pdf, doc, docx, rtf, jpg, jpeg, png, and gif

Terms and Conditions* This field is required.

Signature* This field is required.

ClearSignature or Initials

Client Contact and Insurance Verification Form