Counseling Center of Nashua
 
                                                            One Main Street * Nashua, NH 03064   (603) 883-0005                                    
                                                            148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
                                                            294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
                                                            50 Nashua Road * Suite 305 * Londonderry, NH  03053 * (603) 432-3033
                                                           208 Robinson Road * Suite 204 * Hudson, NH  03051 * (603) 598-9958
                                                           45 Main Street * Peterborough, NH  03458 * (603) 924-3331
                                                           61 NH Route 27 * Unit 10 * Raymond, NH 03077 * (603)689-7602
                                                           
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
                                                           24 Front Street * Suite 304 * Exeter, NH 03833 * (603) 778-2005  
                                                           16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
                                                           319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
                                                                                          Fax all locations: 603-883-0007
                           
                                     

CLIENTS PRESENTING A NEW INSURANCE CARD


Please be aware of the following:

1.  It is your responsibility to make sure:
     a.  your provider(s) is on your new insurance panel
     b.  that if authorization(s) is required, it is in place for your next visit (If an authorization is required --Tufts, Tricare, US Family, Beacon Health, Value Options -- members take note--and not obtained prior to your next visit, you will be asked to pay in full for the visit
     c.  to know what your new deductible and copayment is and to come to your visit prepared to pay in full the portion of your visit you are responsible for.  Please note, at The Counseling Center, your provider is not paid for services he or she delivers to you or your family members if you do not pay at the time of each visit.

**** If you are not able to upload your insurance card images below, please skip down to "Client Information" ****

 

 

 

calendar


May we send you appointment confirmations by mail? *


May we send you billing questions or requested information by email? *

(Required for certain plans, as we cannot obtain benefits info without it, including United Healtcare, United Behavioral Health; BC/BS plans other than Mass; Value Options; Beacon Health)

0/200 characters
0/300 characters
Do you have a second insurance plan?
If Yes, and we have it currently on file, is there any change to this plan?

If we do not have a secondary insurance plan on file, please provide upload photos of the additional insurance cards, and please complete the following for this secondary plan:

 

 

calendar


May we send you appointment confirmations by mail? *


May we send you billing questions or requested information by email? *

(Required for certain plans, as we cannot obtain benefits info without it, including United Healthcare, United Behavioral Health; BC/BS plans other than Mass; Value Options; Beacon Health)

0/200 characters
Please sign this form verifying your review and understanding of this information.  You are also confirming that you understand that your typed name shall have the same legal and binding authority as your handwritten signature.
 
 

Client Information


Complete the Section Below in Full if you are unable to upload an image of your ins. card:



Does this insurance change affect any other accounts? *
If Yes:

New Insurance Information

 If for reasons of privacy or concerns about providing your insurance identification number online despite the fact that this is a secure web page, please at least leave the name of your insurance company so we can appropriately determine who may be on your insurance panel to match your clinical need for an appointment should your present provider not be on your insurance panel.  You may provide your identification number at a later date


I certify the above information is true and correct.  I understand that the purpose of this information is to assure appropriate coordination of benefits of all plans.  I further understand that my typed signature bears all the legal authority as my written signature.