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, I encourage you to also call your insurance company to become familiar with your specific benefits and coverage. If you are planning to utilize an additional funding option (e.g., HSA, HRA, FSA, EAP), please provide detailed information and consult your employer to guarantee the payment of the mental health services.

Individual seeking 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:

 

 

Front:

 

 

 

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.