FGP Insurance Card

Secure Insurance Card Form

To request an insurance coverage estimate or to update your insurance information, please complete this form. For general inquiries, complete our contact form. To schedule your first session, complete our scheduling form.

As a courtesy, we obtain insurance coverage estimates from insurers. Insurance coverage estimates are subject to change and are not payment guarantees.

With your consent below, we will provide your insurance coverage estimate to you by email. If you would prefer to not communicate with us by email, you may instead call us at (914) 533-4950, Monday through Friday, 9:00 AM to 5:00 PM ET.

You may find it easiest to complete this form on your smart phone as photos of the insurance card are required.

Your Name *

Your Date of Birth * 🛈 +

Your Legal Gender * 🛈

Your Email Address *

Email Risk Acknowledgement & Use Consent *

I understand that the use of email is inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Feeling Good Psychotherapy therapists and/or office staff communicating with me by email

Insurance Company *

Insurance Company Phone Number *

Member ID *

To help prevent billing errors, please upload photos of the front and back of the insurance card (two photo files) below.

Insurance Card Photos *

Are you the insurance plan subscriber? * 🛈

Yes

No

What is your relationship to the insurance plan subscriber? *

Subscriber First Name *

Subscriber Last Name *

Subscriber Street Address *

Subscriber City *

Subscriber State *

Subscriber Zip Code *

Subscriber Phone Number *

Subscriber Date of Birth * 🛈 +

Subscriber Legal Gender * 🛈

Are you an existing client? *

Yes

No