Mental Health Counseling Insurance Verification Request "*" indicates required fields HiddenPhone*Do not edit. Pre-filled for your convenience.HiddenEmail*Do not edit. Pre-filled for your convenience. Clinic Name* Patient First Name* Patient Last Name* Patient Date of Birth* MM slash DD slash YYYY Sex* Male Female Patient Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Diagnosis* Insurance Company Name* Member ID from Insurance Card* Provider Services Phone NumberYou can find this number on the backside of the insurance card. Important! Please upload the FRONT AND BACK of the Insurance Card. Upload Front and Back of Insurance Card Drop files here or Select files Max. file size: 256 MB. Δ