Insurance information form

Insurance information form

*Please Note* We are not in-network with Medicare / Medicaid / State-Funded Insurance plans, including but not limited to: Highmark Wholecare, UPMC for You, UPMC for Kids, Geisinger Family (GHP), Aetna Betterhealth, and UnitedHealthcare Community Plan.
Client email address:*
example@example.com
Legal Name is it is displayed on your insurance card:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
home address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Administrative sex listed on your insurance plan:*

Malefemale
Member ID Number (Please include any letters shown):*
Group Number (if applicable):
Date insurance plan became active:

MonthDayYear
Date
Front of insurance card*

Cancelof
Back of insurance card

Cancelof
Are you the primary policyholder?*

YesNo
If you answered 'no' to the question above, what is the legal name of the primary policyholder?

First NameLast Name
Relationship to you:
Primary Policyholder's Date of Birth:

MonthDayYear
Date
Administrative sex listed for primary policyholder:

Malefemale
Address of primary policyholder (only enter if it's different from your address listed above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of primary policyholder (we will not use this to contact this person - it's just required for insurance billing and verification):
Please enter a valid phone number.
Any additional information you'd like to share about your insurance coverage?
Insurance Information & Responsibility Acknowledgment

We want to make sure there are no surprises when it comes to your insurance coverage. While we’re happy to help explain what we can, we always recommend that you check directly with your insurance provider so you understand your benefits for mental health services - including things like copays, deductibles, and session limits.

By signing this form, you agree that:
- You’ve provided accurate insurance information.
- You understand that you’re responsible for any charges your insurance doesn’t cover.
- You’ll let our billing team know if your insurance changes at any point.
We’re here to support you in the process. If you have any questions, please email us at billing@chosenpathcollective.com.
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Insurance information form

Insurance Information & Responsibility Acknowledgment