Client Benefits and Eligibility Check

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*This is a form before services are rendered. After services are rendered, please email Billing and Admin Staff directly at Billing@CounselingProfessionalsPLLC.com
NOTE - This is not a guarantee of coverage or rate. The insurance company's information can be wrong and clients should always check themselves as well. This is only information to the best of our knowledge and resources.

Counseling Professionals Staff (Put None if none yet)

First Name *

Last Name *

Date of Birth *

YYYY

Insurance Company *

Member ID *

Insurance Company Phone Number

Your Email *

Your Phone Number

Best Way to Follow up with You

Phone Call

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If you need to submit any documents for consideration, you can submit this at the HIPAA compliant document sharing form below, but make sure to submit this form as well so we know how to contact you.

https://www.google.com/url?q=https%3A%2F%2Fsignnow.com%2Fs%2FvHbW0rF8%3Fblank_redirect%3Dhttps%253A%252F%252Fwww.counselingprofessionalspllc.com%252Ffor-clients%252Fthank-you-for-documents&sa=D&sntz=1&usg=AFQjCNFlp1Ins_ILLBOLoE9yCYRapkEjDA

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