Client Notification of Insurance Change

Client Notification of Insurance Change

Thank you for letting us know about your recent or upcoming insurance change! This information will help us collaborate with you on next steps.

This form is designed to both educate on the process of insurance changes at the practice and collect important information. It helps us smoothly update your account and work with you to avoid interruptions in care or unexpected charges.

Our hope is to keep you connected to care while making sure that you are not liable for unpaid claims or undue fees. For fees that are not covered by insurance, clients are responsible. Learn more on our detailed "Fees & Insurance" page on our website.

Below are the following insurances we can accept:
Client Information
Client Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter your phone number. Format: (000) 000-0000.
Client Date of Birth

MonthDayYear
Date
AetnaCareOregon (OHP)Kaiser Permanente of the NW/WAMODAPacificSourceProvidence Behavioral HealthSelf-PayTrillium Community Health Plan (OHP)Other
New Insurance Information
Who is your new Insurer?
The name of the Insurance Company or who provides coverage for mental healthcare.
Effective Date of New Policy

MonthDayYear
Date
Please provide your new Policy ID Number:
This may also be called Member ID or Participant ID
Please upload a picture, screenshot, pdf, or document of your new insurance. You can often find an electronic version of your insurance card when you create an online account/profile with your insurance company.)

Uploading your insurance documentation helps ensure accuracy and faster processing. A form without an upload may experience longer processing times. All uploaded documents are stored securely in compliance with HIPAA.
Cancelof
I am the SubscriberSomeone else is the Subscriber
Legal Name of Policy Holder/Subscriber*

First NameLast Name
Birth Date of Policy Holder/Subscriber*

MonthDayYear
Date
Address of Policy Holder/Subscriber*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Policy Holder/Subscriber*
Please enter a valid phone number.Format: (000) 000-0000.
YesNoPrefer not to say
Moving from a Medicaid Policy (OHP, CareOregon, Trillium)
***IMPORTANT NOTE*** If you are moving from a Medicaid (OHP/CareOregon/Trillium) Policy to a new Commercial Policy, you are required by Oregon Health Authority to contact the Oregon Department of Human Services to report this change in circumstance. Both the availability of employer-provided health insurance and the possible change in income could change your eligibility for your Medicaid Coverage. If ODHS finds that you were receiving benefits while ineligible, they may ask for these payments to be reimbursed. This is why we always encourage you to make this call as soon as you know of a change in circumstance.

You can report this change to ODHS (regardless of which Coordinated Care Organization you use) here:
- Phone: (800) 699-9075 (Mon-Fri 7 a.m. to 6 p.m. Pacific Time)
- Email: oregonhealthplan.changes@state.or.us
- OregonONE Portal: https://one.oregon.gov/
More information on reporting changes is available through Oregon Health Authority.
YesNo
What date were you able to report this change? (This can be approximate)
Self-Pay and Out-Of-Network
YesNoOther
Some Insurance Providers allow you to request reimbursement for Out-of-Network benefits. If this is something you would be interested in doing, we can provide you with "Superbills" to ease this process. Payment of our Self-Pay charge of $165 would be due up-front at time of service. You can then use the superbill to submit an Out of Network reimbursement request with your insurance carrier. Please note that we do not provide out-of-network billing or reimbursement submissions on your behalf.
Follow-Up & Final Feedback
YesNo Thanks, I understand my options!
If you would like a call from the Billing Specialist, please provide your best availability for a phone call below:
Please share any additional questions, concerns, feedback, cheers, or ideas that you would like us to know:
Thank you!

We appreciate your communication and information!

We know that insurance changes can be stressful, and these systems can be very hard to navigate. We are here to work with you through it and offer our assistance! We will explore any possible avenues we can to keep you with your current therapist and continue this important work you're doing together!
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Client Notification of Insurance Change

Client Information

New Insurance Information

Moving from a Medicaid Policy (OHP, CareOregon, Trillium)

Self-Pay and Out-Of-Network

Follow-Up & Final Feedback