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