BEFORE YOU VERIFY YOUR BENEFITS

Please use this submission form only AFTER you have scheduled your initial appointment through our receptionist. You may contact us via phone at 512-344-9181 or email at reception@plumeriacounseling.com. Thank you!

"*" indicates required fields

When is Your First Appointment?

Who is your therapist?

Client Information

Client's name as it appears on the insurance card:*

First Last

Client's date of birth:*

Client's gender (of legal record):*

Guardian's name (if client is a minor):

First Last

Insurance Information

Mental health insurance provider:*

Please read the back of your id card to find out what company covers your mental health (it may be different than the carrier listed on the front of your card).

If other, coverage provided by:*

*BCBS HMO* Because BCBS HMO mental health is handled through Magellan we are not in network and there are no out of network benefits, if you would like to use your insurance you must locate an in network provider with Magellan.

Insurance Phone Number*

This is located on the back of the insurance card. Look for a toll-free number that specifies Mental Health.

Insurance ID | Policy Number:*

Group Number:*

FILE UPLOAD (optional)

Drop files here or

Max. file size: 256 MB.

You may upload a copy of the front/back of your insurance card and/or driver’s license here.

NOTES (Optional)

Please tell us if you are aware of anything unique about your insurance coverage we should know about.

Secondary Insurance (Only if applicable)

Secondary Coverage by:

Insurance Phone Number

This is located on the back of the insurance card. Look for a toll-free number that specifies Mental Health.

Insurance ID | Policy Number:

Group Number:

Client Contact Information

Primary contact person:*

Phone:*

Email:*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

If we have a question, how would you prefer to be contacted?*

Note: if there are any questions about your VOB, please contact Plumeria Counseling Center at (512-344-9181).