Insurance Verification Form
Christine Hurst, LCPC will do her best to verify your benefits prior to your first session. However, you are ultimately responsible for any balance not paid insurance. If you would like to contact your insurance company to better understand your benefits you will need to call the phone number on the back of your card for either Behavioral Health, Mental Health, or MH/SA. If these are not on the back of your card, please call the customer service number. Ask the representative for outpatient mental health benefits. Please be aware that the company that provides mental health coverage may be different than your individual insurance company.

Please fill out this form while on the call with the representative.
Email *
Your full name: *
Representative's name that you are speaking with: *
Is Christine Hurst, LCPC (the provider you are scheduled with) in-network?
If not, is Aspire Counseling Center, LLC in-network?
Clear selection
Are the following CPT codes covered: *
Required
Do I need a referral from my doctor?
Clear selection
Do I have a deductible?
Clear selection
If yes, what is my deductible? $
What date does my deductible year restart?
Have I met the deductible?
Clear selection
If no, the amount left $
Do I have a co-pay?
Clear selection
If yes, the amount is
How many visits do I have per year?
Do I need an authorization?
Clear selection
If yes, can you give me one?
Authorization Number
Date Range
Number of sessions covered by this authorization
What is the claims address for outpatient mental health claims? Please note that this address may be different than the address listed on your insurance card.
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