psychatlanta.com - Patient Insurance Information

Patient Insurance Information Update

Please complete and submit the information below so that we can get your insurance updated in our system.
Patient Name: *
Patient Date of Birth:*

MonthDayYear
Patient Contact Phone Number:*
Which location do you visit?
New Insurance Company Name*:*
*If your card states that your mental health benefits are provided by another company please enter both names here. For example: Cigna is on the front of your card, but on the back it says mental health: Optum.
New Insurance Claims Address*:
Member ID:*
*Located on the back of your insurance card. Please enter the claim/mailing address for your mental health benefits.
New Insurance Company Phone:
Date New Insurance Effective:

MonthDayYear
Front of Insurance Card*

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Back of Insurance Card*

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We encourage you to contact your insurance company to verify your mental health benefits and to be sure that your provider is in network with your current insurance provider. Our front office staff will contact you to verify receipt of this request.
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