Insurance Verification Request

All clients, prospective or current, who have new insurance, need to fill out this form so that we can tell you what will and will not be covered with your insurance. After you complete the form, we can let you know ahead of your first (or next) appointment whether we take your specific insurance plan and, if so, approximately what you will owe and what your insurance will pay. If you are a prospective client, please communicate with one of our therapists to make sure we have an opening that will work with your schedule before filling out this form. You can contact the individual therapist you’d like to see by clicking on the contact button near their picture or by calling us directly (847)754-3838.

What therapist do you currently see or plan to see?

Name of Client

First Name

Last Name

Choose One

Prospective Client

Current Client

Email of Primary Correspondent (Client or Parent/Guardian)

Client's Address

Phone Number (Client or Parent/Guardian)

Client's date of Birth

Name of Insurance Carrier (if different from the prospective client)

First Name

Last Name

Date of Birth of Primary Insurance Carrier (if not client)

Address of primary insurance carrier (if not the client)

Phone Number of Primary Insurance Carrier (if different from prospective client)

(###)

###

####

Name of Insurance Company (as written on card)

Member ID (if on card)

Group ID (if on card)

Plan ID (if on card)

Insurance Company Phone Number on Card (for Behavioral Health if there are multiple phone numbers)

Secondary Insurance Information (if available) --including Insurance Carrier Name and any numbers on card

Sex of Primary Client (as recognized by insurance carrier)

Male

Female

Insurance Verification Request

Hope & Healing Psychotherapy 1000 Hart Road, Ste. 205 Barrington, IL 60010

847-754-3838 (phone)

847-550-3708 (fax)