Wellsprings Counseling Center, LLC

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May we EMAIL you a FORM to complete that will speed up the new client onboarding process? Note that there are inherent confidentiality risks in communicating by email. While safeguards are in place to ensure your privacy, you should not use email communication if you are concerned about any breaches of privacy that might inadvertently occur. Checking "Yes" indicates that you are aware of and okay with these risks:Yes

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----- INSURANCE INFORMATION -----

This information is solely used to tell you if we take your insurance.
(THIS SECTION IS OPTIONAL, BUT NECESSARY FOR QUICKER TURNAROUND - We cannot get your insurance benefits without your full subscriber ID and date of birth)

Insured Date Of Birth

Client's Date Of Birth (if different than Insured)

*NOTE: If you have UNITED HEALTHCARE or OXFORD, they will not release your benefits information to us unless you first call them and authorize Wellsprings to be able to get your benefits. That authorization only lasts 24 hours, so alert us immediately at 201-956-6363 x10 after you call and authorize us.

**NOTE: We encourage you to call your insurance as well, and ask them for your outpatient mental health benefits (deductibles, copays/co-insurances) for Wellsprings Counseling Center, LLC, Tax ID 81-0595862.

***NOTE: The insurance Payer ID # is a 3 to 5 digit number used to electronically bill insurance. Not every insurance card lists the Payer ID / Payer Number. Leave this blank if you do not see this number on your insurance card.

To submit this information to Wellsprings, you MUST FIRST ANSWER Security Question: 2 + 4 =