Language
English (US)
Insurance Reimbursement Form
To be completed for verification of benefits
Service Location
*
Clear Lake - Houston
Cypress - Houston
GOA - Clear Lake, Houston
In Home Program
Client's Name
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date Picker Icon
How does the client identify?
Female
Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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Area Code
Phone Number
Phone Number
*
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Area Code
Phone Number
ICD10 Diagnosis Code(s) - This is the code that is paired with the client's diagnosis. Example: One of the codes for ASD is F84.0. Please double check your codes as your doctor may have specified a bit more and put F84.5. You should be able to find these on your doctor's report from the most recent evaluation.
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Insured's Information
Insurance Company
*
Please define this policy as Primary or Secondary:
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Primary
Secondary
Subscriber ID:
*
Group/Plan Number:
*
Employer:
*
Insured's Name
*
Insured's Date of Birth
*
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Month
-
Day
Year
Date
Social Security Number
*
Relationship to Client:
*
Email: Please supply the best email to reach you at as well for us to send important follow-up information to.
Please Supply a FRONT copy of your Insurance Card
*
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Please supply a BACK copy of your Insurance Card
*
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of
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Submit
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