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Right to Receive a Good Faith Estimate of Expected Charges
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
.
If you plan to pay at least partially with out-of-network insurance, you may find it easiest to complete this form on your smartphone as photos of your insurance card will be required on a subsequent page.
Your First Name
*
Your Last Name
*
Your Pronouns
*
Your Email Address
*
🛈
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.
Are you over 18 years of age?
*
Yes
No
Do you have any form of medical insurance (including Medicaid or Medicare)?
*
🛈
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 in-network Healthfirst insurance
Yes, I plan to pay at least partially with out-of-network insurance
No, I plan to pay fully out of pocket and/or with an employer benefit or I don't know
What is your date of birth?
*
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+
Are you currently seeing a mental health provider that is in-network with Healthfirst insurance?
*
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Yes
No
Where would your telehealth sessions typically take place?
*
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In my place of residence
In a location other than my place of residence
Unknown at this time
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?
🛈
The Gender & Sexuality Therapy Center
850 7th Avenue, Suite 1106
New York, NY 10019-0029
gstherapycenter.com
(646) 797-4340