Insurance Paid Services Request Form

Insurance Paid Services Request Form
Requestor Email Address
Please carefully complete the following information about the person that you are requesting Counseling/Therapy services for:
Client Full Name

First NameMiddle NameLast Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Age
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Gender
If the person that you are requesting services for does not have a phone number or email address, please enter the requestor's phone number and/or email address.
Is the Contact Information provided below for a person other than the Client?
if client is child or client has no phone nor email, answer Yes.
Contact Person Name

First NameLast Name
Contact Person Relationship To Client
Client Contact Phone Number
Please enter a valid phone number to contact client.Format: (000) 000-0000.
Client Contact Phone Type
Client Contact Email Address
Please enter email address to contact client: example@example.com
Is there an additional person other than the Client that can be contacted?
e.g. Foster Parent, DFCS Case Manager, CASA
Additional Contact Person Name

First NameLast Name
Additional Contact Person Relationship To Client/Role
Additional Client Contact Person Phone Number
Please enter a valid phone number to contact client.Format: (000) 000-0000.
Additional Client Contact Person Phone Type
Additional Client Contact Person Email Address
Please enter email address to contact client: example@example.com
Client Current Address

Street Address

Street Address Line 2
CityStateZip Code
Client Medicaid ID Number
12 characters - not Subscriber #
Client Insurer
Client Member ID Number
Insurer Member # or Subscriber #, not same as Medicaid ID
Client Insurance Card Front

Cancelof
Client Insurance Card Back

Cancelof
Has this client been seen for this service by another provider in the current year?
Existing Diagnoses Categories

Other
Presenting Problem
List problem behaviors and include any medications for emotional and/or behavior problems
Related Evaluations and Assessments

Attach any completed evaluations or assessments for client e.g. Psychological/Psychiatric Evaluation
Cancelof
Is the child in Foster Care?
Have you confirmed in GAMMIS that the child is not still listed under their Parent's policy?
Please submit AFTER you have confirmed in GAMMIS that the child is no longer listed under their Parent's policy. Failure to do so can significantly delay service delivery.
Preferred Clinician
If you have a specific clinician you would like this referral assigned to
Should be Empty: