Insurance Information Needed Before 1st Office Visit
2. How many visits are you allowed?_________
3. Do you have a
deductible?__________
If so, have you met your deductible?
4. Do you have a co-payment for each visit?___________ If so, what is the amount?
5. Where are claims for insurance payment to be sent? (Sometimes the company
handling behavioral/mental health visits is different than those for
medical).
Insurance Company name_______________________
Address________________________ _______________________