Getting Started

Help us verify the terms of your insurance coverage

Today's Date*
Client Information
Client's name as it appears on the insurance card*
Client's Date of Birth*
Gender (of legal record)*
Insurance Information
Insurance Company*
If other, coverage provided by:
Insurance ID | Policy Number
Group Number
Mental Health Carrier
Please read the back of your id card to find out if mental health is handled through some other insurance company.
Insurance Phone Number
This is located on the back of the insurance card. Look for a toll-free number that specifies Mental Health
Employee Assistance Programs (EAP)
Client Social Security Number (SSN)
Name of EAP Provider
EAP Pre-Authorization Number
This will be provided to you directly from your EAP provider
Number of EAP sessions covered
Start/End Date for EAP Authorization
Client Contact Information
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email Address*
File Upload (optional)
If possible, you may upload a copy of the front/back of your insurance card and/or driver's license here.
Drop files here or
Captcha
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Client Information