Benefits Request

Your Name (required)

Your Email (required)

Phone Number (required)

Your Date of Birth (required)

Please check the back of your Insurance Card to confirm the name of the company that covers your Behavioral Health Care.

Primary Insurance

Name of Primary Insurance Company (required)

Primary Insurance ID Number (required)

Primary Insurance Group Number (required)

Primary Insurance Phone Number (required)

This can be found on the back of your card under Behavioral/Mental Health. If there is not a specific number for Behavioral Health, please provide the main number.

Primary Subscriber-Card Holder Name (required)

Primary Subscriber-Card Holder Date of Birth (required)

Secondary Insurance

Name of Secondary Insurance Company (if applicable)

Secondary Insurance ID Number

Secondary Insurance Group Number

Privacy Question

May we leave a voicemail or send an email reply to the contact information provided?

YesNo

If 'No' was selected, how may we contact you?

Additional Message