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: Aetna PPO, United Healthcare/ Optum PPO, BCBS- Blue Choice PPO, Blue Cross Blue Shield PPO, Blue Cross Blue Shield HMO (ADVOCATE), Cigna PPO, Magellan, & Beacon.

* 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.

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 (Accepts:BCBS, Cigna, and Aetna)Raechel Pierce (Accepts:BCBS, Cigna, Magellan, and Aetna)Alexa Diego (Accepts: BCBS, Aetna, Cigna, Magellan, & Beacon)Kristina Slacum Jones (Accepts:BCBS, Aetna, Cigna, Magellan, & Beacon)Carrie Wallace (Accepts: BCBS, Aetna, Cigna, Magellan, & Beacon)Andres Carrion (Accepts: BCBS & Magellan)

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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.

Please note that clients are required to attend minimum 8 individual psychotherapy sessions to be able to request any formal letters or paperwork (e.g., letter for emotional support animals, FMLA paperwork) from Roamers Therapy LLC.