Patient's Relationship to the Insured/Subscriber:
Insurance Carrier Information:
INSURANCE CARRIER ADDRESS
NAME OF INSURANCE CARRIER
Name of Insured/Subscriber (As shown on the insurance card):
Insured/Subscriber I.D.# & Group #:
"My full legal name will act as my signature."
"I authorize the release of any medical or other information necessary to process my claim. I authorize payment of medical benefits to the physician or supplier for services described on my claim."
The charges for services provided may or may not be covered by your insurance carrier. You are advised to check with your insurance carrier as to the extent of coverage and psychological services.
Click this box for a checkmark to indicate "Yes I grant authorization"
REQUIRED: Please enter your first and last name to complete the assessment.
All information sent is held as strictly confidential.