NYC Therapy + Wellness
Insurance Information
Please enter your insurance information below so that we may file claims on your behalf.
Name *
First, Last
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Today's Date *
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Email Address *
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Phone Number *
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Date of Birth *
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Address on file with insurance company *
Street, apt., city, state, and zip code.
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Name of Insurance Provider *
(i.e., Anthem Blue Cross Blue Shield)
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Insurance Phone Number *
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Insurance Member ID *
This is not your group number.
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Payer ID
(i.e.UnitedHealthCare is 87726)
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Name of Primary Insured *
Only fill out if Primary Insured is NOT self or client. If self, type "self" in the answer box.
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Relationship to the Primary Insured *
Insured's Date of Birth
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Insured’s Address on File with Insurance
Street, apt., city, state, and zip code.
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Insured’s Phone Number
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What services are you interested in using insurance for? *
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By signing my name below, I hereby give NYC Therapy + Wellness permission to submit insurance claims on my behalf. *
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