Heritage Counseling Center - Benefits Verification

Benefits Verification
Patient's Full Name*
Patient's Date of Birth*

MonthDayYear
Insurance Subscriber's Full Name*
Insurance Subscriber's Date of Birth*

MonthDayYear
Phone Number*
Email*
Address*
Counselor Scheduled With*
Date of First Appointment*

MonthDayYear
Insurance Company Name*
Insurance Customer Service Phone*
Insurance Mental Health Phone (optional)
Insurance ID Number*
Insurance Group Number*
HMO Medical Group (optional)
Should be Empty: