Insurance and Copay Form

Please complete the following information for insurance and billing purposes - your copay or coinsurance.

Please refer to your benefits plan for any costs. We will bill your card for any copay on the day of the appointment.

Any costs derived from the billing of the psychological evaluations and report which is billed at the end of the testing, will be discussed prior to payment.

Patient First Name *

Patient Last Name *

Street Address *

Zip Code *

Full Name on Credit Card *

Credit Card Number *

Expiration Date of Credit Card * +

CSV (security number) *

Email Address for Confirmation *

Insurance Provider *

Insert photo of front of insurance card

Insert photo of back of insurance card

Please press the submit button once you have entered all fields. Thank you.