The Gender & Sexuality Therapy Center | Secure Insurance Card Form

Secure Insurance Card Form

Secure Secondary Insurance Card Form

As a courtesy, we obtain insurance coverage estimates from insurers. Insurance coverage estimates are subject to change and are not payment guarantees. You may find it easiest to complete this form on your smartphone as photos of the insurance card are required.

We do not accept in-network insurance, but are considered out-of-network providers. Please see our frequently asked questions page for more information.

Your First Name *

Your Last Name *

Your Pronouns *

Your Email Address * 🛈

Your Phone Number 🛈

Please acknowledge that emails and text messages should not contain sensitive information. * 🛈

I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.

Your Date of Birth * 🛈 +

Your Gender According to Insurance * 🛈

Are you an existing client? *

Are you providing insurance information that is effective next year? * 🛈

Do you have secondary insurance? *

Withholding additional insurance information can greatly impact your billing costs and proper payment to the practice. If your insurance plan changes, or if you receive an additional insurance plan, it is important that you supply the insurance information promptly. If you have applied for any additional state benefits or will in the future, such as disability, please let us know right away as we may need to make adjustments to your claims. Please initial here to indicate your understanding. *

Please refer to your physical insurance card when populating the remaining fields.

Insurance Company *

Healthfirst

Modern Health

Other Other

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? * 🛈

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 Gender According to Insurance * 🛈