PHP & IOP Inquiry Form

Schedule a PHP/IOP Consultation

If you are a referring client, please fill out the below fields with your patient's information.
Insurance Provider*
Aetna Plans*
Note: if you do not see your plan listed, we are most likely not in-network with your provider
Blue Cross Blue Shield Plans*
Note: if you do not see your plan listed, we are most likely not in-network with your provider
Cigna Plans*
Note: if you do not see your plan listed, we are most likely not in-network with your provider
United Plans*
Note: if you do not see your plan listed, we are most likely not in-network with your provider
Date of birth

MonthDayYear
Date
Please enter your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Optional: Check Your Insurance Coverage

If you would like us to check your insurance benefits, please provide the following information. If you do not wish to provide your insurance information at this time, please submit your form as is.
Insurance Provider Phone Number
Member ID Number
Upload a photo/scan of the front AND back of your insurance card

This will help speed up the process to check your insurance benefits
Cancelof
Subscriber's Last Name
Subscriber's First Name
Insurance Address as Listed on Your Insurance Card

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber's Relationship to Client

SelfSpouseParent/GuardianOther
Please verify that you are human*
Should be Empty:

Schedule a PHP/IOP Consultation