G. Update My Insurance

Update My Insurance
Please provide your new/updated primary
health insurance information below.
We will update your file to minimize any insurance billing delays.

1. Provide information for your new/updated health insurance - front and back of the card. Please provide the name, date of birth, address, and the relationship to you of the person who is the primary subscriber on the health insurance plan.

2. Contact your health insurance company and ask them about your benefits for Outpatient Mental Health Counseling. What is your copay? Does your medical deductible need to be met before your insurance will help pay for services? Depending on your coverage, having to meet a deductible first can mean a difference of a $25-30.00/copay or $85.15-125.00/copay cost.

All clients are responsible for knowing their health insurance benefits and for paying their co-pays. Most insurance carriers do not pay for counseling sessions until the yearly deductible has been met. Also note, many insurance carriers only cover a portion of the cost of Tele-Therapy sessions.
Primary Health Insurance*

N/AAetnaAetna MedicaidAnthemBuckeye Health Ambetter/MarketplaceCaresource MedicaidCaresource MarketplaceCignaCigna EAPCornerstone AcademyCompsych EAPDennison UniversityHumanaMedical MutualMedicaidMedicareOhio Healthy MedicaidOhio Healthy PPOOptum UHCOptum UHC EAPOptum UHC MedicaidUMRTricareOther
Client's Name*
Member ID: member id*
Group ID: group id*
Subscriber Name:subscribers name*
Subscriber DOB:Date of Birth*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   relationship*
Please Copy Front And Back Of New Primary Insurance Card*

*** Click "Browse Files" to find and upload front of card. Then click "Browse Files" again to find and upload back of card. ***
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Do you have secondary health insurance information to update? (Please note, we are not currently taking secondary health insurances at this time.)

YesNo
Secondary Health Insurance*

N/AAetnaAetna MedicaidAnthemBuckeye Health MarketplaceCaresource MedicaidCaresource MarketplaceCignaCigna EAPCornerstone AcademyCompsych EAPDennison UniversityHumanaMedical MutualMedicaidMedicareOhio Healthy MedicaidOhio Healthy PPOOptum UHCOptum UHC EAPOptum UHC MedicaidUMRTricareOther
Member ID: member id*
Group ID: group id*
Subscriber Name:subscribers name*
Subscriber DOB:Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   relationship*
Please Copy Front And Back of Secondary Insurance Card*

*** Click "Browse Files" to find and upload front of card. Then click "Browse Files" again to find and upload back of card. ***
Cancelof
Should be Empty: