Insurance Verification Form

What’s covered by my insurance?

Roamers Therapy LLC will verify your benefits and we will consult prior to your first session what your out of pocket costs will be. However, we encourage you to also call your insurance company to become familiar with your specific benefits and coverage. Please remember that verification of benefits does not guarantee payment from your insurance company. This process might take up to 14 days or more depending on the number of request we receive. You may temporarily be added to a waitlist while we verify your insurance benefits.

If you are planning to utilize an additional funding option (e.g., HSA, HRA, FSA, EAP, etc), please provide detailed information and consult with your employer to guarantee payment for mental health services.

Accepted Insurance: Blue Cross Blue Shield PPO, BCBS – Blue Choice PPO, Aetna, Cigna, United Health Care/ Optum.

* Roamers Therapy does not accept any other HMO, Medicaid, nor Medicare plans. Please contact your customer service line that can be found on your insurance card to locate a provider that does.

Scheduling Frequency: Roamers Therapy works off a weekly scheduling model and we are not able to accommodate infrequent scheduling, such as (bi-weekly, monthly, or sporadic).

  1. Research shows that clients who go to psychotherapy on a weekly basis either make significantly more progress or deteriorate much less compared to those who go to psychotherapy on a biweekly basis.
  2. Our clinicians, too, noticed in the past years that their clients did not reach desired psychotherapy goals and experienced adverse effects during bi-weekly scheduling.  
  3. Psychotherapy Modalities utilized for individual and couples therapy highly recommend weekly scheduling to see folks meet their goals and improve functioning.

If you have any additional questions, please use our frequently asked questions page:

CLICK HERE TO ACCESS FAQ

    Individual seeking sessions

     

     

    What are you looking forward to working on in therapy?
    What goals do you hope to achieve?

    What is your scheduling preference for weekly sessions?

     

     

    Primary Insurance information

    Relationship to Client
    SelfParentSiblingSignificant Other

    Do you have second insurance carrier?

    Will you be utilizing HRA, HSA, FSA, EAP or similar plans? If so, provide more information:

     

     

    Preferred therapist(s):
    AnyCandice Love (Accepts: BCBS PPO, Blue Choice PPO, & UnitedHealthCare)Shaysa Villa (Accepts: BCBS PPO, Blue Choice PPO, & UnitedHealthCare)Raechel Pierce (Accepts:BCBS PPO & Blue Choice PPO)Carrie Wallace (Accepts: BCBS PPO & Blue Choice PPO)Andres Carrion (Accepts: BCBS PPO & Blue Choice PPO)

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    Front:

     

     

    Are you currently an Illinois resident?
    YesNo

     

     

    Please complete this form in its entirety. Once your benefits have been verified this does not guarantee you are a client of Roamers Therapy LLC.



       
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