NYSHIP Form

NYSHIP Insurance - Carelon Behavioral Health
Patient Name:*

First NameLast Name
Patient Date Of Birth:*

MonthDayYear
Date
Patient Phone Number:*
Email*
example@example.com
Member ID:*
Patient Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are You The Policy Holder?*

YesNo
Policy Holder Name:*
Relation To Policy Holder: *
Policy Holder Date Of Birth:*

MonthDayYear
Date
Out Of Network Billing & Deductible Information:

Please note that while South Shore Psychiatry accepts NYSHIP/Beacon insurance, we bill it as an out-of-network provider. This means that the patient is responsible for any out-of-pocket costs if they have not reached their out-of-network deductible. The out-of-network costs are similar to our private pay rates which are ($350 initial appointment / $185 for the follow-up) until the patient has met their out-of-network deductible. It is the patients responsibility to call their insurance company to see if they have met their out-of-network deductible and if once met, if there are any additional costs associated with their coverage. It usually takes 2-3 visits for you to meet your out-of-network deductible for the whole year.
Please Upload The FRONT Of Your Insurance Card: *

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Please Upload The BACK Of Your Insurance Card: *

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Please Upload The FRONT Of The Policy Holders License: *

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Should be Empty:

NYSHIP Insurance - Carelon Behavioral Health