The Center for Trauma, Stress, and Anxiety Inquiry
Thank you for considering The Center for Trauma, Stress, and Anxiety for your care! 
We are honored that you are considering us. Please answer the following questions so that our team can reach out to you when an opening becomes available that best fits your needs. 
                                                            _________________________________________

*Insurance: Our practice is In-Network with the following insurance plans: 
  • BlueCross/BlueShield CareFirst HMO, PPO, Federal & BlueChoice plans- (excluding Medicaid, Medicare, and EAP)
  • Cigna EverNorth- (excluding Medicaid, Medicare, and EAP)
  • John Hopkins EHP
  • John Hopkins USFHP
If your primary insurance is through an insurance company or plan not listed above, you are considered Out-of-Network or 'Self-Pay' at CTSA. If you choose to proceed with care as a self-pay client, we are happy to provide you with a 'Superbill' on a monthly basis that you can use to submit for reimbursement from your insurance provider. 
                                                            _________________________________________

**Medicaid clients only**
Due to Medicaid guidelines, we cannot provide Out-of-Network services to Medicaid clients. To find a Medicaid provider near you, go to:  https://encrypt.emdhealthchoice.org/searchable/main.action
Sign in to Google to save your progress. Learn more
Who would you like to connect to: 
Check all that apply
 *
Required
First Name *
Last Name *
Phone Number: *
Email Address: *
Preferred method of contact: *
Required
How did you hear about us? *
Tell us about yourself and/or the client:  Chief Concerns, Symptoms, Preferences, and/or Scheduling Needs *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Center for Trauma, Stress, and Anxiety, LLC. Report Abuse
Google Forms