Accepted Insurance

We accept BCBS, Medicare, Humana, Aetna, Cigna, UBH/Evernorth, Tricare East: We do not accept HMO plans.

Once you’ve scheduled an appointment, please complete the following form so that we can conduct a benefits verification. This occurs one week prior to your appointment.

Benefits Verification Form

Patient Full Name

Patient Date of Birth

Phone Number

Email Address

Patient Address

Name of Policy Holder

Policy Holder's Date of Birth

Policy Holder's Address

Policy Holder’s Relationship to Patient

Patient Gender

Name of Insurance

Patient ID #

Patient's Group ID #

Telephone Number on the Back of Insurance Card for Mental/Behavioral Health Benefits (or number "for providers")

Referring Providers Name

Telephone Number on Back of Insurance Card for Medical Benefits (or number "for providers")

List All Reasons for the Appointment (e.g., anxiety, ADHD, learning disability, memory, etc.)

Have you already scheduled an appointment with us?

Yes No

If Yes, please enter date and time of your appointment

*Please Attach a Picture of Your Insurance Card(s): Front and Back

Accepted Insurance

Benefits Verification Form

Have Questions?