Letter of Support Request
**PLEASE READ THE FOLLOWING PRIOR TO COMPLETING AND SUBMITTING THIS FORM**

By filling out the form you acknowledge you have read and understand the following:

  • Dr. Bartel is only accepting patients ages 18+ 
  • All appointments will be completed virtually 
  • Dr. Bartel is able to see patients in the following states; AL, AZ, AR, CO, CT, DE, DC, FL, GA, ID, IL, IN, KS, KY, ME, MD, MI, MN, MO, NE, NV, NH, NJ, NC, ND, OH, OK, PA, RI, SC, TN, TX, UT, VA, WA, WV, WI, WY 
To learn more about the Letter of Support Process click here.

Self-Pay Rate (WPATH Letter)

  • Letter for Gender Affirming Hormones (GAHT) $150 
  • Letter for Gender Affirming Surgery $200 
Insurance Payment Options:

FLORIDA Residents Only:
  • Insurance Accepted: Aetna, Oscar, Oxford, United Healthcare
  • Please note: if your plan is affiliated with Medicaid or Medicare, I will not be able to accept your insurance at this time
  • All insurance payments will be completed using Headway; click here to learn more or to set up an account 
  • I am also able to accept the following virtual plans Blue Cross Blue Shield of Massachusetts & Horizon Blue Cross and Blue Shield of New Jersey
Out of Network Payment Options:

I've partnered with Mentaya, a service that streamlines getting reimbursed for your therapy sessions through out-of-network benefits.

Mentaya is perfect if you have out of network benefits and are unsure about the process of submitting paperwork for reimbursement or simply want to skip the hassle of paperwork!

How it works:
    1. Sign up for Mentaya here 
    2. Our practice will enter your session into the platform.
    3. Mentaya submits the claim and handles any insurance follow-up.
    4. You get reimbursed by insurance!

Mentaya charges a 5% fee per claim, which includes handling any paperwork required, dealing with denials, and calling insurance companies. For example: If your appointment is $200 you would pay Mentaya $10 to submit the claim. If your appointment is $150 you would pay Mentaya $7.50.

It's risk-free: They guarantee claims are successfully submitted, or a full refund of their fees.

How do I learn more about my out of network benefits?

Mentaya should be able to verify if your insurance has out of network benefits. You can also contact your insurance provider or employee benefit plan.

Depending on your current health insurance provider or employee benefit plan, it is possible for services to be covered in full or in part. When you contact them you can verify how your plan compensates you for psychotherapy services and if you have the ability to meet with a provider out of network. 
I would recommend asking these questions of your insurance provider to help determine your benefits:
  • Does my health insurance plan include mental health benefits?
  • Do I have a deductible? If so, what is it and have I met it yet?
  • Does my plan limit how many sessions per calendar year I can have? If so, what is the limit?
  • Do I need written approval from my primary care physician in order for services to be covered?
  • What information do they need for Out of Network Services and how do I file a claim?

Please contact me for any additional questions you may have. I look forward to hearing from you! 

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Email *
I have read and understand the above information *
Legal Name (First & Last) *
Chosen/Affirmed Name
Date of Birth *
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What pronouns do you use?
What labels do you use to describe you gender?
What labels do you use to describe your sexual orientation?
Full Address *
What state are your currently located in? *
Phone Number *
What type of letter are you requesting? *
Required
If you are requesting a letter for surgery, when is your surgery date?
When will you need the letter completed?
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Does your insurance, physician, etc. also require you to complete individual therapy for 12+ months?
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Do you have all the contact information for the surgeon, physician, or clinic who is requesting the letter? Please provide it here (name, address, phone number, fax number) *
Have you been hospitalized for any mental health reason in the past 6 months? *
Are there any particular days or times that work best for you to schedule an appointment?
Preferred Method of Contact
If you are a Florida resident, do you have insurance through any of the following companies (please note: if your plan is affiliated with Medicaid or Medicare, I will not be able to accept your insurance at this time)?
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If you are a Florida resident, are you are interested in using your insurance to pay for your visit? All insurance payments are completed using Headway Click here to learn more or to set up an account.
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Do you have out of network mental health benefits through your insurance?
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If you have out of network mental health benefits through your insurance would you like me to submit your appointment for reimbursement through Mentaya?
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Please provide your insurance information here (include the policy holder name, name of insurance, member ID)
Any other information you would like to share?
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