Self-Pay Profile Request Form

Each Regional Billing Specialist will create SimplePractice profiles for self-pay clients. They will include the appropriate CPT codes and session rates. If a sliding scale rate has been negotiated between clinical & client, that rate must be shared with your Specialist.

Please send all billing and/or insurance inquiries to your Regional Billing Specialist.

(This form is to be completed by Three Oaks clinician, on behalf of client)

Region A: Erik Hall
Downtown Raleigh, East Raleigh, North Raleigh, West Raleigh, Midtown
RegionA@threeoaksbehavioralhealth.com

Region B: Josh Wereszynski
North Durham, South Durham, Chapel Hill, Southern Village
RegionB@threeoaksbehavioralhealth.com

Region C: Lisa Moore
Telehealth, Garner, Pittsboro, Apex
RegionC@threeoaksbehavioralhealth.com

Billing Region

Name of Clinician:

First Name

Last Name

Client's Legal Name:

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.

Client's Sex:

These are currently the only options available in SimplePractice.

Client's Date of Birth:

Client's Email:

Client's Phone Number:

(###)

###

####

I am requesting

A new SimplePractice client profile.

An update to an existing client profile.

Requested Profile Type

Please select all that apply.

Individual

Minor

Couples

Individual in Group Therapy

Psychological Testing/Evaluation

Session Location

Where will the majority of your sessions take place?

[For Couples] Partner's Legal Name:

First Name

Last Name

[For Couples] Partner's Date of Birth:

[For Couples] Partner's Email:

[For Couples] Partner's Phone Number:

(###)

###

####

[For Minors] Parent's/Guardian's Legal Name:

First Name

Last Name

[For Minors] Parent's/Guardian's Email:

[For Minors] Parent's/Guardian's Phone Number:

(###)

###

####

Rates

Please indicate your negotiated rates below if they differ from the practice's rates.

Will you be using Three Oaks' self-pay rates?

Yes

90791 Rate

90837 Rate

Self-Pay Profile Request 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

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