Insurance Verification Form

I need to verify insurance benefits for: *

Please choose one of the following.

Client's LEGAL Name *

First

Last

Must match the name listed with insurance.

Client's Preferred 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.

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 *

Email: *

Phone Number *

Policyholder's Relationship to Client *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Therapist's Name *

First

Last

What is the name of your Three Oaks therapist? If you have not yet been connected with a therapist on our team, please first submit a contact form. We look forward to welcoming you to the practice!

Session Location *

How will you be meeting with your therapist?

Requested Therapy

Individual
Family
Couples
Group

Please select all that apply.

Spouse's Date of Birth *

Documents Needed to Complete Verification

Before uploading an additional document, please verify that the document's name and file size appear in the box.

Photo ID of Policyholder *

Click or drag a file to this area to upload.

Please upload a photo of your government issued ID (for example, driver’s license or passport).

Front of Insurance Card *

Click or drag a file to this area to upload.

Please upload a photo of the FRONT of your insurance card.

Back of Insurance Card *

Click or drag a file to this area to upload.

Please upload a photo of the BACK of your insurance card.

Additional Information/Comments

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!

Documents Needed to Complete Verification