Insurance Pre-Authorization

Please allow 72 hours 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 Card
Alternatively, 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.)*

Insurance Card