Insurance/Employee Assistance Benefits (EAP)

Please provide health insurance, even if you are using EAP Benefits.

Health Insurance Company*

Member Name*

Member DOB*

Member/ID Number*

Group*

Phone number (found on back of card)*

Please note—we do not bill secondary insurances.

Employee Assistance Program, if Applicable

Name of EAP

Authorization Number*

Number of Sessions

Start Date* Dates of Authorization, if applicable

End Date

Phone Number of EAP

You must notify us of EAP benefits PRIOR to being seen. Only one EAP authorization per person/family. After one EAP authorization, self-pay or insurance will be utilized.

As a courtesy to you, we will verify your insurance coverage and based on that, we will give you our best ESTIMATE of what your insurance company will towards your services here.

PLEASE NOTE, IT IS ULTIMATELY YOUR RESONSIBILY TO UNDERSTAND YOUR BENEFITS AND TO INFORM US OF ANY CHANGES. You are responsible for any balance left unpaid by your insurance company. Please feel free to contact your insurance company for additional information.

By signing this, I agree this is an ESTIMATE, and my credit card on file will be charged outstanding balances, as agreed upon on the Credit Card Statement Form, and I will be notified prior to any such charges, if any.

Signature*

Reset

Date*