Insurance Pre-Authorization Please allow 14 business days for pre-authorizations Name of policy holder* First Last Policy holder's date of birth*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name of patient First Last Patient's address (if different from policy holder) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Patient's Date of Birth*Name of Insurance*Patient's ID #*Patient's Group ID #*Telephone number on the back of insurance card for Mental/Behavioral Health benefits (or number "For providers")*Telephone number on back of insurance card for Medical Benefits (or number "For providers")*Name of Referring Physician First Last (if applicable)Insurance CardAlternatively, you can fax a copy of the front and back of the patient's insurance card to 469-549-4201. If you do not have access to a camera phone or fax, please bring your cards with you to your appointment.Please take a picture of the FRONT of the patient's insurance card and upload:Please take a picture of the BACK of the patient's insurance card and upload:Name of Person Completing This Form*Email Address* Phone Number of Person Completing This Form*List all reasons for the appointment (e.g., anxiety, ADHD, learning disability, memory, etc.)*