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.

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?

 

 

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):
AnyShaysa Villa (16 + weeks waitlist)Raechel Pierce (6+ weeks wait-list; Accepts:BCBS PPO & Blue Choice PPO)Kristina Slacum Jones (6+ weeks wait-list; Accepts:BCBS PPO & Blue Choice PPO)Carrie Wallace (6+ weeks wait-list; 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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