New Client Contact Form (Page 2 of 2) in pdf

New Client Contact Form Page 2

Name on Insurance Card : ____________________________________________________________________

Insurance ID#:___________________________________

Group#: ___________________________

Member Phone #: _______________________________ Provider Phone #:___________________________

Behavioral Health Phone #: ________________________________

Partner (B): Insurance company name:_________________________________________________________

Name on Insurance Card: ____________________________________________________________________

Insurance ID#:___________________________________

Group#: ___________________________

Member Phone #: _______________________________ Provider Phone #:___________________________

Behavioral Health Phone #: ________________________________

Please note that you are responsible for submitting your receipts to your insurance company. We retain your

insurance information in case we need to contact your insurance company to answer any questions.

New Client Contact Form Page 2