Billing Question Form
Share your billing, copay, insurance claim, or refund question—our client care team will respond within 2 business days.
Client full name
*
First Name
Last Name
Client date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/guardian or account holder name and relationship
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to reach you
*
Email
Phone
Text message
Issue type
*
Charged for a session I did not attend or a late cancel/no-show fee
Copay or balance looks wrong
Insurance claim denied or not processed
Refund request
Need a statement, receipt, or superbill
Update my payment method
Something else
Insurance carrier
Please Select
Aetna
Cigna
UnitedHealthcare / Optum
Florida Blue
Oscar
AvMed
Ambetter
Molina
Simply
Carelon (EAP)
Lyra (EAP)
Headspace (EAP)
Military OneSource (EAP)
Headway
Self-pay
Other
Clinician you see
Please Select
Dr. Jason Prendergast
Dr. Fran Johnson
Dr. Azhany Haynes
Dr. Genesis Ettienne
Sylvia Hooks
Lauren Butler
Melanie Vohs
Clinical intern
Not sure
Session date(s) in question
Amount in question (USD)
Describe the issue. Please do not include diagnoses or clinical details. Billing details only.
*
Upload a statement, EOB, or receipt
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Send to Client Care
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