Insurance Benefits Request Form

Patient Name *

First Name Last Name

Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Patient Date of Birth *

Date

Patient Diagnosis *

Patient Insurance Company *

If you have United Healthcare, please call the number on the back of your insurance card prior to (or immediately after) submitting this form. You will need to provide verbal permission to allow Graham Behavior Services to check your benefits.

If you do not have United HealthCcare, there is no need to take this step. Thank you!

United Healthcare Reference Number (if applicable)

Patient Insurance Member ID *

Patient Insurance Group Number

if applicable

Policy Holder Name *

First Name Last Name

Policy Holder Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Policy Holder Date of Birth *

Date

Policy Holder Phone *

Please enter a valid phone number.

Policy Holder Email

example@example.com

Employer of Policy Holder

Insurance Plan or Program Name

if applicable

Individual Completing Form Name *

First Name Last Name

Individual Completing Form Phone *

Please enter a valid phone number.

Individual Completing Form Email

example@example.com

Relationship to Patient *

parent, guardian, grandparent, etc.

Patient Insurance Card *

Front and Back Required

I hereby give my consent for Graham Behavior Services, LLC (GBS) to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Graham Behavior Services, LLC Notice of Privacy Practices provides a more complete description of such use and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. GBS reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to GBS. With my consent, GBS may mail to my home or other designated location and leave a message on voicemail or in person reference to any items that assist the practice in carrying out TPO, such as therapy reminders, insurance items, and any call pertaining to my clinical care, including assessment results among others. With my consent, GBS may email to me therapy and patient statements. I have the right to request that GBS restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.By signing this form, I am consenting to GBS use and disclosure of my PHI to carry out TPO. A copy of GBS’s Notice of Privacy Practices will be provided upon my request. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, GBS may decline to provide treatment to me. *

Clear