Name of the Inspirit therapist you will meet with:* First Last Name* First Middle Initial Last Please provide your (the client’s) first and last name exactly as printed on your health insurance card.Date of Birth* MM slash DD slash YYYY Please provide your (the client’s) date of birth as mm/dd/yyyy. Click the calendar icon to select a date as well.Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* The best email address can we use to contact you.Home Phone*Mobile Phone*Work Phone*Insurance InformationInsurance Company Name* Member ID Number* Group Number* Are you the subscriber (policy holder)?* Yes No Subscriber Name* First Middle Initial Last Relationship to Subscriber*SpouseChildEmployerLife PartnerOtherSubscriber Date of Birth* MM slash DD slash YYYY Please provide the subscriber's date of birth as mm/dd/yyyy. Click the calendar icon to select a date as well.Employer Name* The name of the employer associated with this insurance policy. Do you have a secondary insurance policy?* Yes No Secondary Insurance InformationSecondary Insurance Company Name* Secondary Insurance Member ID Number* Secondary Insurance Group Number* Are you the subscriber (policy holder) of the Secondary Insurance?* Yes No Secondary Insurance Subscriber Name* First Middle Initial Last Relationship to Subscriber*SpouseChildEmployerLife PartnerOtherSecondary Insurance Subscriber Date of Birth* MM slash DD slash YYYY Please provide the secondary insurance subscriber's date of birth as mm/dd/yyyy. Click the calendar icon to select a date as well.The information you are submitting on this document will be processed by Accurate Medical Billing, Inc., a third-party administrator contracting with Inspirit Counseling Services to provide this verification. All eligibility and benefit information obtained will be securely delivered to your Inspirit provider, within 2 business days of your submission. Verification of eligibility and benefits are not a guarantee of coverage until any claims associated with your treatment are fully processed by the insurer. Thank you. PRIVACY POLICY All employees with Inspirit Counseling Services, Inc. and Accurate Medical Billing, Inc have signed a confidentiality agreement. All your personal information will be held in strictest confidence. A copy of the confidentiality policy for Inspirit Counseling Services, Inc and/or Accurate Medical Billing, Inc is available upon request.CaptchaType the five characters in the box above.
