Insurance Form The Better You Institute

Name *

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Last

Date of Birth (mm/dd/yyyy) *

Dropdown

Email *

Phone Number *

What is the best way to contact you? *

Phone
Email

What is the best time to contact you? *

Morning
Afternoon
Evening

Do you have insurance? *

Yes
No

Name as it appears on your insurance card *

First

Last

Address linked to your insurance (Street, Apt., City, State, Zip Code) *

Address Line 1

Address Line 2

City

State

Zip Code

Last 4 digits of your Social Security number *

Insurance Company Name (Ex: Blue Cross Blue Shield of Pennsylvania; Aetna) *

What type of plan do you have? *

PPO
HMO
I don't know.

Insurance Company's Phone Number *for the provider (listed on the back of your card) *

Member ID including letters (not group number) *

What services will we be checking coverage for? *

If you are an existing client, which therapist do you see?

How did you hear about us? *

If you were referred by another provider, may we please have their name and practice so that we can thank them?

Questions or Comments

By typing my name below, I hereby give The Better You Institute, LLC the right to access my insurance information and benefits and relay them to me. (First and last name) *

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Signature *

Insurance Form
Therapy & Counseling
Philadelphia, PA

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Locations We Serve:

Insurance FormTherapy & CounselingPhiladelphia, PA

Address

Email

Insurance Form
Therapy & Counseling
Philadelphia, PA