Insurance Verification - New Reflections Counseling, P.A.

Insurance Verification | New Reflections Counseling

Insurance Verification Form

Your Name

Your Phone Number

Your Email

Date of Birth (month/day/year)

Social Security Number

For Couples Therapy:

*Partner Name

*Partner Phone Number

*Partner Email

*Partner Date of Birth (month/day/year)

*Partner Social Security Number

*Partners Insurance Company Name and Policy Group Number or Member ID number

Insurance Company Name

Is this a Medicare or Medicaid policy?

yes no

Policy/Member Service phone number on the back of the insurance card

Group Number

Member ID number

Plan ID number

Session type

Picture of front of insurance card

Picture of back of insurance card

Your Full Address (including State and ZIP Code)

How did you find us?

Web search (Google, etc) Word of mouth Insurance Instagram Facebook

Comments and any other information you think we'll need

By submitting this form, you authorize New Reflections Counseling to verify your insurance benefits on your behalf. This is not a guarantee of coverage.

By providing a telephone number to New Reflections Counseling and submitting the form you are consenting to be contacted by SMS text message for confirmation and communication regarding scheduling (our message frequency may vary). Message & data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for more information. See our Privacy Policy.