subject_line
Your Rights and Protections Against Surprise Medical Bills
Secure Scheduling Form
To schedule your first session, please complete this multi-page form. For general inquiries, complete our
general contact form
. To request a benefits estimate, complete our
insurance card form
. You may
call us at (718) 260-6042
with any questions.
You may find it easiest to complete this form on your smartphone as photos of your insurance card are required on a subsequent page, if you plan to pay at least partially with insurance.
Your First Name
*
Your Last Name
*
Your Email Address
*
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Your Phone Number
*
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Please acknowledge that emails and text messages should not contain sensitive information.
*
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I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.
Would you like to receive updates by email about new services?
Yes, I would like to receive updates by email from Cobb Psychotherapy LCSW about new services being offered to clients
Do you have any form of medical insurance (including Medicaid or Medicare)?
*
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Yes
No or I don't know
Do you plan to pay for your sessions at least partially with insurance?
*
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Yes, I plan to pay at least partially with insurance
No, I plan to pay fully out of pocket and/or with an employer benefit (e.g. Lyra Health) or I don't know
Your Date of Birth
*
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+
Did you already provide your insurance information using our
insurance card form
?
*
Yes, I already provided my insurance information
No, I did not already provide my insurance information
What is the name of your employer?
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COBB PSYCHOTHERAPY LCSW
450 7TH AVENUE • SUITE 809 • NEW YORK, NY 10123
26 COURT STREET • SUITE 401 • BROOKLYN, NY 11242
cobbpsychotherapy.com
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(718) 260-6042