Insurance Verification

Insurance Verification

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In order for us to verify your insurance, please fill out the following form.

If you have already emailed us your insurance card and provided your info via your client portal, there is no need to submit it twice.

Client Info - Step 1 of 9

We verify insurance even if you are utilizing EAP benefits in case you would like sessions beyond your EAP sessions.

Name *

First

Last

Do you have an appointment requested/scheduled?

Clinician you requested/scheduled an appointment with:

Phone Number *

Email *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

For Couples (clients seeking individual therapy can skip)

Please provide us with your partner's demographic information. They will be sent an email with a link to their client portal to fill out their first session forms.

Are you interested in couples therapy? *

Yes
No
Maybe

Partner's Name

First

Last

Phone Number

Primary Insured's Information (if self, put self and skip this section).

If you are not the primary insured, this could be your spouse, parent, domestic partner, etc.

Your relationship to the primary insured: *

Primary Insured's Name

First

Last

Primary Insured's Date of Birth

Primary Insured's Address

Address Line 1

Address Line 2

City

State

Zip Code

Please select your primary insurance *

If your insurance is not listed, please provide the name of it below

Insurance ID# *

Group ID# *

Customer Service # on the back of your card *

Please upload the front of your insurance card. (Optional, but helpful!)

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload the back of your insurance card. (optional, but helpful!)

Click or drag a file to this area to upload.

Is this your primary and only insurance coverage? *

Yes (can skip next section)
No, I have other secondary insurance

Secondary Insurance Info. If you only have one insurance policy, you can skip or if you are the primary insured on your secondary insurance policy, you can skip.

If you are not the primary insured, this could be your spouse, parent, domestic partner, etc.

Secondary Insurance: Primary Insured's Name

First

Last

Secondary Insurance: Your relationship to the primary insured:

Secondary Insurance: Primary Insured's Date of Birth

Secondary Primary Insured's Address for Secondary Insurance

Address Line 1

Address Line 2

City

State

Zip Code

Please select your secondary insurance

If your secondary insurance is not listed, please provide the name of it below

Secondary Insurance Member ID#

Secondary Insurance Group ID#

Secondary Insurance: Customer Service # on the back of your card

Please upload the front of your insurance card. (Optional, but helpful!) (copy)

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload the back of your insurance card. (optional, but helpful!) (copy)

Click or drag a file to this area to upload.

If you were referred by an EAP company, please provide the EAP company name and your authorization number, if you have one. If you do not know the name of your EAP company, please provide us with the number you called for your authorization.

Please provide us with any additional Notes About Your Insurance Benefits

Please provide us with any notes for your therapist regarding your care

Benefit Check Disclaimer

At DK Therapy, we strive to remove barriers to seeking counseling and verify insurance coverage and benefits for new and established clients so that you can be made aware of their potential fees prior to your appointment. We try to be as accurate as possible when verifying benefits, your fees may change depending on your eligibility and benefits during the date of your sessions. When we email you your benefit information, that is an estimate as of that date, and we won't know your exact fee until we bill your insurance and get your explanation of benefits back from your insurance company. Ultimately, you are responsible for knowing your insurance coverage and we encourage you to call the number on the back of your insurance card and ask your member representative about your 'mental health, outpatient, office visit' benefits.

I have read and understand the Benefit Quote Disclaimer. *

Cancellation Policy

DK Therapy requires notification (call or e-mail) at least 24 hours prior to your appointment if you need to cancel or reschedule. A cancellation fee of $75 will be charged to your account at the time of your appointment if you fail to notify us at least 24 hours prior to your appointment.

I have read and understand the Cancellation Policy. *

How did you hear about our services? *

Name

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410 S. Michigan Ave. Suite 928

Cancellation Policy

Please note that we require a 24-hour notice if you decide to cancel your appointment. Call or email to cancel or reschedule at least 24 hours before your scheduled appointment in order to avoid charges. We will do our best to accommodate you and appreciate your cooperation. Thank you.

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