Permission to Contact Insurance
By filling out this form, you authorize your therapist to contact your health insurance and inquire about your mental health benefits.
Email *
Name as it appears on your insurance card (First and Last name) *
Your telephone number *
Address linked to your insurance (Street, Apt., City, State, Zip Code) *
Date of Birth (mm/dd/yyyy) *
Last 4 digits of your Social Security number *
Insurance Company Name (Ex: Blue Cross Blue Shield of Pennsylvania; Aetna) *
What type of plan do you have? *
Insurance Company's Phone Number * For the provider (listed on the back of your card) *
Member ID including letters (not group number) *
By typing my name below, I hereby give Jessica Pavelka Counseling, LLC the right to access my insurance information and benefits and relay them to me. (First and last name) *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy