Billing Update Form

Billing Update Form
This form is for established or returning clients who are wanting to update their billing preference. If you are an established or returning client, please complete all required fields of this Billing Update Jotform and click submit when completed. Once received our office will contact you within 2 business days.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Chosen/Preferred Name
Date of Birth*

MonthDayYear
Date
Phone #*
By entering your phone number, you are consenting to receiving calls and voicemails from Mindful Counseling's staff.
Email*
By entering your email address, you are consenting to receiving emails from Mindful Counseling's staff.
Email is not considered a secure medium and therefore, confidentiality cannot be assured. Please use discretion when sending information that is sensitive in nature.
What type of counseling services are you currently receiving from, or wanting to resume with Mindful Counseling?*

IndividualFamilyCouples
What is the name of your MC Provider? If you are a former client, what was the name of your previous MC provider?*

Payment Options:
A description of the two payment options Mindful Counseling offers, to include a list of the insurance companies our billing staff can bill, is located in the PAYMENT OPTIONS tab of our website, www.mindfulcounseling.org
How would you like to pay?*

Private Pay: If you choose Private Pay, the rate is $95 per session and your form is complete.Insurance: If you choose Insurance, Mindful Counseling will need your policy’s identifying information and Mental Health, Office and Telehealth benefits. We suggest contacting your insurance company to obtain the information necessary to complete this Jotform. Missing or incorrect information about your policy can delay the process of securing an appointment and can result in compounding billing issues that may result in out of pocket expenses.

Your insurance requires Mindful Counseling to retain a copy of your insurance card for your chart. Please upload a photo of the front and back of your insurance card. *

Insurance Card Front
Cancelof
Insurance Card Back
Cancelof
New Insurance Company Name
New Insurance Policy's ID #*
New Insurance Policy's Group #*
New Insurance Policy's Effective Date*
If Mindful Counseling was billing a different insurance policy prior to this change, when will that policy terminate? *
If the client is not the policy holder, indicate the policy holder’s information:
Is the identified client the insurance policy holder?*

YesNo **If No, policy holder's information will be obtained.

Deductible amount:*
If your mental health benefits apply to your policy's deductible, this information is required in order to estimate how long you will be paying towards your deductible.
Deductible amount met to date:*
If you meet, or have met your annual deductible, the client cost share often drops to a lower co-insurance or even to $0.
Co-insurance amount, after deductible is met:*

Co-pay Amount:*
If the co-pay is different for Office Visits and Telehealth Visits, please indicate both co-pay amounts here.

What is the policy’s Out of Pocket Max?*
If your policy's annual Out of Pocket Max is met, the client cost share can drop to $0 until the policy renews.

Do you have an Employee Assistance (EAP) or Health Savings/Flex Spending Benefits?*

NoYes **If Yes, please research how to utilize these benefits and prepare to discuss the details with Mindful Counseling's biller.
Do you have a secondary insurance (Coordination of Benefits)?*

NoYes **If Yes, please provide your secondary insurance policy’s information.

Secondary Insurance Company Name*
Your insurance requires Mindful Counseling to retain a copy of your insurance card in your chart. Please upload a photo of the front and back of your secondary insurance card. *

Front of Insurance Card
Cancelof
File Upload*

Back of Insurance Card
Cancelof
Secondary Insurance Policy's ID #*
Secondary Insurance Policy's Group#*
Does this secondary insurance policy run on a calendar year?*

YesNo
If no, what month does the secondary insurance's renewal?
Its common for benefits (client cost share) to change when a policy renews.
Is the identified client the secondary insurance policy holder?*

YesNo **If No, policy holder's information will be obtained.