Benefits Inquiry Form

Benefits Inquiry Form

By completing this form, you authorize our staff to contact your insurance to verify your mental health benefits. You will receive an email from us with a summary of our findings. Please note this is a complimentary quote, and not a guarantee of benefits. It is ultimately your responsibility to be familiar with your insurance coverage.
Requesting Party Information
Name*

First NameLast Name
Preferred Contact Email*
example@example.com
Preferred Phone Number
Optional
Prospective Client Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Name of Insurance Company*
Insurance ID #*
Please upload a picture of the front & back of your insurance card

Cancelof
Click here if you'd like to add a second insurance
Name of Secondary Insurance Company
Insurance ID #
Please upload a picture of the front & back of your secondary insurance card

Cancelof
Please be aware that benefits are determined by your insurance and are in no way controlled by Aspen Ridge Counseling. Quotes provided from this form will be a reflection of your current benefit balances as quoted by your insurance company and may change with the filing of more claim. Therefore this estimate will be most accurate if used immediately.
You'll be redirected to our website after your successful submission
Should be Empty:

Requesting Party Information