Massachusetts Sleep and Counseling Center Appointment Request
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Which part of Massachusetts are you living in?
*
Please Select
Metropolitan Boston
Rest of State
Are you paying with insurance?
*
Yes
No, I want to pay out of pocket (~$170 per session)
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Thanks! We'll help you verify your insurance coverage and provide you with a cost estimate.
Your Insurance Company
*
Please Select
Blue Cross Blue Shield of Massachusetts
Optum Behavioral Health
Beacon Health Options
Magellan Health
Harvard Pilgrim Health Care
Others
Insurance Name
Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Member ID
You can find this on your insurance card or by calling your insurance company
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Preferred appointment time (optional)
E.g., Thursdays after 5pm or Wednesday from 9am to 12pm
Anything else we should know? (optional)
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Submit
Should be Empty: