Insurance Information Form

Insurance Information Form

Please fill in the form below so we have all your information.
If you are requesting a benefits check from us, it can take up to 48 hours to complete the benefits check. A quote of benefits does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service.
What type of provider are you planning to see at Discovery?
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Who is the client that will be accessing services at Discovery?

MyselfA Minor childAn Adult Dependent
We just need a little more information about the client you are contacting us about:
Client's Name:

First NameLast Name
Client's Relationship to you
Client Contact Number

Area CodePhone Number
Client Email
example@example.com
I give permission for Discovery Counseling Austin to communicate with my (or my dependent's) insurance company for the purpose of benefits check and billing.

YesNo
Client's Date of Birth

MonthDayYear
Date
Company or School providing the insurance
AAA University, ABC Tech Company, Self-employed plan, etc.
Member ID #
Group ID #
Customer Service Phone Number
Typically on the back of the card
Additional Customer Service Phone Number
If you can't tell which # is the best customer service #
Are you the Primary Insured or is your plan through a parent or partner?

Yes, I'm the primary insuredNo, my plan is through a parent, partner or someone else.
Primary Insured Full Name (parent, partner, etc.)

First NameLast Name
Primary Insured's Gender
This is an occasional requirement of insurance, feel free to leave blank if you are not comfortable answering and we can discuss this with you if we need it.
Primary Insured's date of birth (Required)

MonthDayYear
Date
Primary Insured's Address (Required)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Front of Insurance Card

Browse Files

Cancelof
Back of Insurance Card (optional)

Browse Files

Cancelof
Is there anything else you'd like us to know about your insurance situation or information you already have about your benefits?
INSURANCE CONSENT

By consenting below,

* I understand that if I choose to use insurance, I am authorizing the release of any medical or other information necessary to process claims. I also request payment of benefits to Discovery Counseling Austin, for services provided and claimed.

* I also understand that my insurance may not cover an “out-of-network” provider, a provisionally licensed provider and/or I may have a deductible to meet on my insurance plan and therefore I will be responsible for the counseling fees.
Consent to pursue treatment using insurance.

Yes, I consentNo, I don't consent.
Thank you for sharing this information!
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