Insurance Evaluation Form for Prospective Clients

You indicated that you do not wish to allow At Your Pace Counseling, LLC to evaluate your insurance benefit information.

I agree with this statement and authorize At Your Pace Counseling, LLC to review my insurance benefit information.
I do not agree / authorize.

You indicated that you do not wish to allow At Your Pace Counseling, LLC to evaluate your insurance benefit information.

Please contact our Office Manager at wroberson@aypc.email to discuss how to procede.

Client Information

Client's Legal Name

First

Middle

Last

Client's Administrative Sex

Client's Date of Birth

Client's Address

Address Line 1

Address Line 2

City

State

Zip Code

Client's Phone Number

Insurance Policy Information

Insurance Company

Member/Beneficiary ID Number

Priority of Insurance Policy

Insurance Policy Group

Please leave blank if you’re unsure.

Insurance Plan Name

As indicated on Insurance Card

Insurance Policy Holder's Information

Insurance Policy Holder's Relationship to Client

Self
Spouse
Parent / Child Relationship
Other

Insurance Policy Holder's Name

First

Middle

Last

Insurance Policy Holder's Administrative Sex

Insurance Policy Holder's Date of Birth

Insurance Policy Holder's Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Policy Holder's Phone Number

Client's Email Address

Release of Information & Assignment of Benefits

Please check each of the following boxes to indicate that you understand and agree to each of the following:

I authorize the release of information from my medical record to the insurance company or other third-party payer named above. This information shall include all information necessary to submit and process claims, such as my name, date of birth, address, medical diagnosis, and services provided to me.
If the practice has already shared information with the insurance company or other third-party payer at the time I revoke this authorization, it is too late to prevent that information from being shared.
This authorization is necessary for the practice to determine eligibility for treatments or benefits or to pay for treatments I receive, but the practice cannot condition treatment on the provision of this authorization.
This authorization shall be effective for 1 year from the date of my signature, unless I contact the practice in writing any time prior to then to revoke.
If you are using Medicare benefits, you also agree to the following: I request that payment of authorized Medicare benefits be made either to me or on my behalf to the name of provider of service and (or) supplier for any services furnished to me by that provider of service and (or) supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related service.
In consideration of the services provided to me, I assign all benefits to the practice, if accepted, and authorize this insurance company to make payments directly to the practice and its affiliates on
I will submit a clear photographs of the front and back of my insurance card to this practice by uploading them into this form or emailing the photos to office@aypc.email.

Clear Photograph of Client's Insurance Card

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Acknowledgement

I authorize At Your Pace Counseling, LLC to release information to the insurance companies provided on this form in order to submit insurance claims on my behalf. This authorization extends to the extent necessary to obtain payment for the services provided to me, and includes authorization to release information about mental health, substance use, or HIV diagnoses as required. In consideration of the services provided to me, I assign all benefits to At Your Pace Counseling, LLC if accepted, and authorize my insurance companies, Medicare, or other third-party payers to make payments directly to At Your Pace Counseling, LLC and its affiliates. I understand that I remain responsible for all amounts due by me, including (but not limited to) copays, coinsurance, deductible amounts, and all services not covered by my insurance plan (including those for which I fail to obtain prior authorization), and mutually agreed-upon services or fees that are deemed not medically necessary. I understand that I must send a clear photograph (or scan and send) a picture of the front of my insurance card to office@aypc.email, so that it can be placed in my electronic file before I can schedule my first therapy session. I understand that fees related to court appearances, subpoenas, depositions, attorney meetings, etc. will not be billed through insurance and I am responsible for their payment. I also attest that I’ve read, understood, and agree to At Your Pace Counseling, LLC’s policy regarding court and associated fees.

benefit the of

Client / Responsible Party's Name

First

Last

Date Submitted

Insurance Evaluation Form for Prospective Clients

You indicated that you do not wish to allow At Your Pace Counseling, LLC to evaluate your insurance benefit information.

Client Information

Insurance Policy Information

Insurance Policy Holder's Information

Release of Information & Assignment of Benefits

Acknowledgement

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