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, Midtown)
RegionA@threeoaksbehavioralhealth.com

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

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

Region *

Three Oaks Clinician's Name *

First

Last

I am requesting: *

A new profile to be created.
An update to an existing profile.

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 *

Client's Sex

Currently, these are the only options available in SP. We are hopeful that this will be updated soon!

Client's Email *

Client's 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? *