Insurance Form
Fields marked with an * are required
Email *
Name *
Phone *
Date of birth *
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Address *
Insurance company *
Insurance phone number (located on the back of the card, labeled "for providers") *
Does your insurance card say "EPO" or "Exclusive" on the front? *
Does your insurance card say "PPO" on the front? *
Member ID *
Group number, if applicable
What state are you in currently? *
Do you also have Lyra Health? *
How did you hear about us? (ZocDoc, Google, Facebook, Good Therapy, Psychology Today, Instagram, etc.) If a doctor referred you, could you please share their name? *
By signing my name below, I hereby give Thriving Center of Psychology permission to obtain my mental health insurance benefits and relay them to me. *
Today's Date: *
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A copy of your responses will be emailed to the address you provided.
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