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:



Please select all that apply.
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.
Currently, these are the only options available in SP. We are hopeful that this will be updated soon!
Where will be majority of your sessions take place?