Insurance Verification Form

Please complete the below form to verify insurance benefits with Crescent and Crown Therapy.

Once submitted, Crescent and Crown will work to verify your benefits. Upon verification, we will consult you on an estimated out-of-pocket cost prior to your first session. We encourage each patient to contact your insurance company and familiarize themselves with your specific benefits and coverage.

Please note: Verification of benefits does not guarantee payment from your insurance company. This is only a quote of benefits. This process can take up to 10-14 business days.

General Patient Information

Name

First Name

Last Name

Date of Birth

Pronouns

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Therapy Modality

Please note: All sessions are only offered via teletherapy at this time.

Therapist Preference

What are you hoping to accomplish with therapy?

What are you scheduling preferences for therapy sessions?

Insurance Information

Primary Insurance Provider

Policy Holder Name

Member ID Number

Group Number

Policy Holder Relationship to Client

Self

Significant Other/Spouse/Partner

Parent

Will you be utilizing HSA/HRA/FSA or similar plans?

*We do not accept Health Maintenance Organization (HMO), Employee Assistance Program (EAP), Medicare or Medicaid.

HSA

HRA

FSA

N/A

Terms and Conditions

I am a current resident of Illinois.

I agree