Insurance Questionnaire                                    
PLEASE READ THIS!       It is required that you call your insurance company to fill out this form.  An answer of “I don’t know” or any other avoidance of the question is not acceptable and will cause your form to be rejected.  Gaining understanding of your insurance benefits is the reason you are being asked to call your insurance company and complete this form.   If you have a secondary insurance, you should complete two of these forms and call both companies. Secondary insurance may pay for services your primary insurance denies, but you will still need to know if your therapist is in or out of network and how that insurance works. The questions below will help you get the information you need to avoid billing surprises.  If I have a waiting list, you will be added to it and contacted when I have an opening.  
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Email *
Today's date *
Your name (first and last) *
Your date of birth *
Your complete legal address (ex.  10 Smith Rd., Apartment 1, Syracuse, NY 13210) *
Your Phone number *
What days are you available for an appointment?  I do not have any appointments available after 4pm as I work 9-5.   *
Required
Brief description of what you are seeking to address  (for example anxiety) *
What is the name of your insurance company? *
What is your insurance subscriber ID#? *
Who is the subscriber for your insurance: Full name, date of birth, and relationship to me or just write "self" *
What is the provider phone number for your insurance company.  It is typically found on the back of your insurance card.  
 *
Ask the following questions when you CALL your insurance company:                                                                        Do I have coverage for mental health or behavioral health services? *
Do I need an authorization for CPT codes 90791 or 90837?  If so, can I obtain it now?  Type authorization number below if provided one by representative *
Does my insurance policy cover teletherapy sessions?   *
Do I need to get a referral from my primary care physician before I see a mental health provider *
Is Wellness Therapy Services LCSW, PLLC or Shannon Freeman an in-network provider for your plan? *
 How much is my deductible?  *
Have I met my deductible for the year? 
 *
Does my deductible apply to outpatient mental health services?
 *
If I have not met my deductible, how much will sessions cost me?
 *
What will my co-pay be for an in-network provider? *
My signature below indicates agreement that the information I provided here is true and factual.  I agree to have this information as well as any clinical information required to be released to my insurance company for the purpose of billing, claims, insurance audits and authorizations.   I also understand that by using my insurance, my insurance company has full access to the contents of my patient file with or without my written permission.  By entering my name into the signature field below, I agree that it constitutes my electronic signature and is the equivalent, and has the same force and effect, of my handwritten signature.                          Please type your full name and today's date below                                                                     *
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