Insurance Verification Form

I need to verify insurance benefits for: *

Please choose one of the following.

Client's LEGAL Name *

First

Last

Client's Preferred Name/Nickname *

Client's Date of Birth *

Policyholder's Relationship to Client *

Policyholder's LEGAL Name (if not the client)

First

Last

Policyholder's Date of Birth (if not the client)

Email *

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!

Requested Therapy

Individual
Family/Couples
Group

Please select all that apply.

Photo ID *

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!