Insurance Card and ID Card Submission Form (Behavioral Solutions P.C.)

Insurance Card and ID Card Submission Form
Please submit the information below regarding your insurance plan so we can ensure your insurance claims are being processed properly with accurate and current insurance information.

This form is for existing or newly scheduled clients only. If you are insterested in becoming a new client please complete the "Become a New Client" form on our website!
Date

Month Day Year
Date
Client's Full Name *

First Name Last Name
Client's DOB *
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is this for a new client or an existing client updating their insurance? *

New Client Existing Client
Therapist Name: *
What is the effective date of this new plan?
Insurance Company *
ID Number
Who is the primary subscriber of this insurance (in relation to the client)? *

Self Spouse or Partner Parent or Guardian
Subscriber's Name

First Name Last Name
Subscriber's DOB
Insurance Card

Please help us assure that all your insurance claims are processed properly. Send us a photo of the front and back of your insurance card. Please try to get the insurance card centered evenly in the screen.
Please take a picture of the FRONT of the card *
Please take a picture of the BACK of the card *
ID Card

Please send us a photo of the front side of your drivers license or state identification card. This is important for verifying your identity when billing your insurance. For minors, please submit the identification card of the parent or guardian.
Please take a picture of your State ID or Driver's License
Please verify that you are human *
Should be Empty: