Demographic/Insurance Update

Demographic/Insurance Update

demographic/insurance update
We need to update your information and insurance cards. Please take a moment to enter your information. Even if your insurance has not changed we need updated copies of your insurance card(s).

Please attach a copy of the front and back of your insurance card (s).

If your insurance has changed, please let the office know. If we do not receive your new insurance information within 48 hours of your appointment, the self-pay rate OF $175 will apply.

Please note that insurance updates submitted after appointments that come back with claim(s) being denied will result in the patient being fully responsible for the charges. Patients will need to submit directly to their insurance for reimbursement.

For questions please call the office at 904-853-5900
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date of Birth
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1 (Required)

Name/ Relationship Phone Number
Emergency Contact #2

Name/ Relationship Phone Number
Please attach copies of the front and back of your insurance cards and Drivers License. If you do not have insurance cards, please attach any letter or other documentation you have

Cancelof
Please select the answer the best fits your insurance coverage:

I have Primary InsuranceI have Primary and Secondary InsuranceI do not have Insurance (Self pay rate of $175 will apply)
Primary Insurance Information
Do you have a secondary Insurance Policy?

NoYes
Secondary Insurance Information
Thank you for taking the time to ensure we have your updated contact information. For any questions please call 904-853-5900 or email us at information@beachesbehavioral.com

About Our Services:

Beaches Behavioral: General and substance abuse psychiatry- outpatient services

Beaches TMS & Brain Health: We offer second opinion evaluations and treatments for patients with treatment resistant depression, depression with anxiety, OCD and others. Patients will be presented with options that are medically appropriate for their diagnosis and circumstances with therapeutic modalities like TMS or Spravato (Esketamine). All of our programs are supervised and overseen by Alina M. Galliano-Pardo, MD (Board certified in Psychiatry and Addiction medicine).

To learn more about our services please visit www.beachestms.com or call 904-853-5900.
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