Does My Health Insurance Cover Treatment at Parakletos Therapeutic Services & Discipleship?

Please provide us with as much as this information on this form as possible, and we will contact you ASAP about your coverage for treatment. All information provided will always be kept strictly confidential.

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Contact Name

First

Last

(If you are seeking help for someone)

Contact Person's Phone

(If you are seeking help for someone) 999-999-9999

Email *

Patient's Name *

First

Last

Patient's Location

ZIP / Postal Code

Patient's Date Of Birth *

mm/dd/yyyy

Name of Insurance Company *

Name of the Primary Insurance Policy Holder

(if different from the patient)

Patient's Policy or Member ID#

Insurance Policyholders Date of Birth

mm/dd/yyyy

Group Number

Customer Service Contact Phone #

(Usually located on the back of the insurance card.)

Any Questions or Specific Concerns?

Whom May We Thank for Referring You to Us?

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