Insurance Verification Form

Clients who wish to bill therapy sessions through their insurance must complete this verification form prior to their first Three Oaks appointment. Please visit our [FAQ page] to learn more!

*Please note: To avoid response time delays, please ensure you indicate the name of your Three Oaks clinician below.

For insurance related questions, please email our Billing Team: clients@threeoaksbehavioralhealth.com

Client's Legal Name:

Must match the name listed with insurance.

First Name

Last Name

Client's Name/Nickname:

We recognize and honor that many of our clients identify by names other than their current legal name and know, express, and/or identify their gender in a non-binary way.

I am a:

new client

existing client (insurance has changed)

Clinician's Name:

Name of therapist you are working with.

Client's Sex:

Must match the sex listed with insurance. (Gender selection for insurance claim forms only includes male or female, binary options.)

Client's Date of Birth:

Client's Email:

Client's Phone Number:

(###)

###

####

Policyholder's Relationship to Client:

Policyholder's Legal Name:

First Name

Last Name

Policyholder's Sex:

Must match the sex listed with insurance. (Gender selection for insurance claim forms only includes male or female, binary options.)

Policyholder's Date of Birth:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Session Location:

Where will you be meeting with your therapist?

Requested Therapy / Service

Please select all that apply.

Individual

Group

Psychological Testing/Education

Required Documentation

Please ensure each document's name & file size are visible after uploading.

Is the attached insurance your primary coverage?

Three Oaks only files with primary coverage. Clients with secondary or out of network insurance will be provided with a Superbill for possible reimbursement.

Additional Comments:

How did you hear about us?

Insurance Verification Form

Thank you for your submission! We look forward to connecting with you. Please allow 3 business days for a response.

Three Oaks Behavioral Health & Wellness

Mailing Address

Contact Us