The Art Therapy Medicaid Insurance Form

Art Therapy Medicaid Insurance Form

Please fill out the following form to help us process your insurance coverage for art therapy services.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Parent/Guardian

First NameLast Name
Do you have Medicaid insurance?*

YesNo
Are you currently enrolled in Medicaid?*

YesNo
Insurance Provider Company*
Insurance Provider Member ID*
What Are Your Goals For Attending The Art Of Healing Workshops*
Signature to authorize the use of insurance information.*

Powered by Jotform SignClear
Should be Empty: