Client Health Insurance Information

Client Health Insurance Information Form

Please complete and sign this form. A copy of your insurance card (front and back) will also be required at the time of delivery of this form.

Last Name

First Name

Date of Birth

Age

Sex

Male Female

Marriage Status

Address

City

State

Zip

Phone Number

Occupation

Employment Status

Employed Student Unemployed

Primary Insured (if different from above)

Last Name

First Name

Date of Birth

Click the button above to send photos of your insurance card (front & back) jpg or pdf. Max file size 20 MB

Employee Assistance Program (EAP) Information (if applicable)

EAP Company

Phone

Employer

Authorization #

Number of Sessions

Mental/Behavioral Health Insurance Information

Insurance Company

Phone

Client ID #

Group #

Copay Amount

Deductible Amount

Today’s Date

I authorize the release of any medical or other information necessary to process this claim. I also request payment of benefits to Clarillette Heredia, LMFT of Solutions Corner, LLC.

Client Signature (Client’s Parent/Guardian if under 18)