Self-Pay Profile Request Form

Each Regional Billing Specialist will create profiles for self-pay clients, adding the appropriate CPT codes and rates. *Please note: If a sliding scale rate has been negotiated, that rate must be shared with the Regional Billing Specialist. Please send all billing and/or insurance questions to your Regional Billing Specialist:

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

Region B: Lisa Moore (Knightdale, Garner, Telehealth)
RegionB@threeoaksbehavioralhealth.com

Region C: LaShawn Willingham (Pittsboro, Southern Village, Chapel Hill, South Durham, North Durham)
RegionC@threeoaksbehavioralhealth.com

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Region: *

Clinician (First & Last Name): *

Requested Profile Type *

Individual
Couples
Individual in Group Therapy

Please select all that apply.

Client's LEGAL Name *

First

Last

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 Date of Birth *

Email: *

Phone Number *

Spouse's Date of Birth *

Session Location *

Where will be majority of your sessions take place?

Will you be using the Three Oaks self-pay rates? *

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