INSURANCE VERIFICATION

Insurance Verification Form

We will email you the results within 24 hours
Client Information:
Client's full name*

First NameLast Name
Current Date

MonthDayYear
Date
Client's Date of Birth*

MonthDayYear
Date
Age (in days)
Age (in years)
For minor clients, please provide the parent or legal guardian's information
Parent's full name*

First NameLast Name
Phone number*
E-mail*
for minors, add parent's email
Is {ClientsFullNameIVF} the policyholder? Yes No*
Is {parentsFull} the policyholder? Yes No*
Please fill out the insurance policyholder information below:
Policyholder's Full Name*

First NameLast Name
Policyholder's Date of Birth*

MonthDayYear
Date
Select your insurance (We are not in network with Medicare, Medicaid of EAP's)*

AETNABlue Cross Blue ShieldCignaOscarOxford Health PlansUnited Health CareOther
{ClientsFullNameIVF}'s relationship to {policyholdersFull} is: *
According to Texas Administrative Rule §681.35, therapists must have a copy of the custody agreement when parents are divorced, prior to the start of treatment.

More information here.
Please select the option that applies to your situation:*

Not applicable, parents are marriedYes, I understand. We are divorced and both parents agree.Yes, I understand. I am the sole consenting caregiver.No. I will reach back once I have the final decree. (We can still check your insurance)
Please provide the name, phone number, and email address of the other consenting caregiver:
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
"By signing below, I authorize Minds In Action Counseling and it's representatives to request and obtain my insurance benefits and coverage details on my behalf."*

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Front side-Upload Insurance Card *

Cancelof
Back side-Upload Insurance Card *

Cancelof
Are you in contact with one of our therapists already?*

YesHelp me select a therapist
Which therapist(s)?*

Abby ZandevakiliAshley HembrockBradley HutchinsonCarla PintoFlora Lai /賴沅萱Griselda RuvalcabaKeegan FriedrichsLupita LopezMaribel FaucettSara AguilarShlomit OlielVeronica Petty
Should be Empty:

Insurance Verification Form

Client Information:

For minor clients, please provide the parent or legal guardian's information

Please fill out the insurance policyholder information below:

According to Texas Administrative Rule §681.35, therapists must have a copy of the custody agreement when parents are divorced, prior to the start of treatment.

More information here.

Please provide the name, phone number, and email address of the other consenting caregiver: