Full Name
*
Your Name (if different than the patient)
Email Address
*
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consent
*
By submitting my information I consent to receive service-related emails, SMS messages, and phone calls from Strata Outpatient, including appointment reminders and support updates. Reply STOP to opt out. Message and data rates may apply.
Marketing Consent
By submitting my information I consent to receive marketing emails, SMS messages, and phone calls from Strata Outpatient. Reply STOP to opt out. Message and data rates may apply.
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Insurance Provider
*
Please Select
Aetna
Anthem Blue Cross
Blue Shield of California
Carelon Behavioral Health
Cigna
First Health
Health Net
Kaiser Permanente
Magellan Health
MHN
Optum
TRICARE
UnitedHealthcare
UMR
Other
I don't have insurance
I'm not sure
Plan Type
*
Please Select
PPO Insurance
EPO Insurance
POS Insurance
HMO Insurance
Medicaid/Medicare
Self-Pay
No Resources
Unsure
Member ID
*
Group ID
Photo of FRONT of your insurance card
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of
Photo of BACK of your insurance card
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Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who are you checking coverage for?
*
Myself
My client
My child or dependent
Another family member or friend
Which program are you asking about??
*
Intensive Outpatient Program (IOP)
Medication management with psychiatric provider
Individual therapy
I'm not sure
Message
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