Insurance Intake Form

Please carefully read and submit the following Insurance Intake Information.

Client/Child's Name*
First Middle Last
Parent Phone Number*
Home Address*
Street Address Address Line 2 City State ZIP Code
Insurance Information
Are you using insurance benefits to cover all or part of therapy services?*
If you are using insurance, indicate whether you are:
Insurance Company Name*
Insurance Company Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company ID #
Group #
Policy Holder's Name
First Last
Policy Holder's Date of Birth
MM slash DD slash YYYY
Policy Holder's Employer
Co-Pay Amount
Have you reached your deductible?
Co-Insurance
Front of Insurance Card
Max. file size: 195 MB.
Back of Insurance Card
Max. file size: 195 MB.
Insurance Information Release
Consent to Release Insurance Information
By clicking this box, I hereby authorize Therapy and Wellness Connection to release to my insurance company, any information regarding this dx which is required to process my claims.
Assignment of Insurance Benefits:
Consent for assignment of insurance benefits.
By clicking this box, I hereby assign my insurance benefits to Therapy and Wellness Connection.
Today's Date*
MM slash DD slash YYYY
Name of person filling out this form.*
First Last

Insurance Information