The Counseling Center Of New England

One Main Street * Nashua, NH 03064 * (603) 883-0005

8 Auburn Street * Nashua, NH 03064 * (603) 883-0005

15 Trafalgar Square * Nashua, NH 03063 * (603-883-0005

148 Coolidge Avenue * Manchester, NH 03102 * (603) 627-3111

294 D.W. Highway * Merrimack, NH 03054 * (603) 883-0005

77 Gilcreast Rd * Suite 3000 * Londonderry, NH 03053 * (603) 432-3033

45 Main Street * Peterborough, NH 03458 * (603) 924-3331
414 State Street * Unit 2 * Portsmouth, NH 03801 * (603) 334-2533

24 Front Street * Suite 100 * Exeter, NH 03833 * (603) 778-2005

16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222

53 Baxter Boulevard * Portland, ME 04103 * (603) 883-0005

61 NH Route 27, Unit 10 * Raymond, NH 03077 * (603) 689-7602

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" ****

If you are able to upload a HIPAA compliant confidential photo of the front and back of your insurance card, then only minimal information is needed from you, as indicated below. If you are not able to upload a card, please skip to the section below labeled "For Patients Unable to Upload a Copy of Their Insurance Card": FRONT of CARD:

BACK of CARD:

Upload HRA or FSA Card (if applicable) to cover any portion not covered by insurance,

I authorize The Counseling Center to charge my HSA/FSA card for any deductibles or copayments or unpaid insurance due balances. My typed signature below authorizes....and I understand that it carries the same legal authority as my handwritten signature. ** Please Initial **

Date: * +

TCCON Account # (if known):

Priovider's Initials:

May we send you appointment confirmations by mail? *

Yes

No

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

Yes

No

Email Address *

Patient Name:

Patient DOB:

Employee Holding Insurance:

Insurance Holder's DOB:

Employer Name:

Employee Social Security Number:

(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)

If other family members in our care are also now covered by this plan, please indicate their names:

0/200 characters

Any other changes that should be added to your account (account responsible, phone number, address, email?

0/300 characters

Do you have a second insurance plan?

Yes

No

Please list the name of that plan:

If Yes, and we have it currently on file, is there any change to this plan?

Yes

No

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:

If you are able to upload a HIPAA compliant confidential photo of the front and back of your insurance card, then only minimal information is needed from you, as indicated below. If you are not able to upload a card, please skip to the section below labeled "For Patients Unable to Upload a Copy of Their Insurance Card": FRONT of CARD:

BACK of CARD:

Date: * +

TCCON Account # (if known):

Provider's Initials:

May we send you appointment confirmations by mail? *

Yes

No

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

Yes

No

Email Address *

Patient Name:

Patient DOB:

Employee Holding Insurance:

Insurance Holder's DOB:

Employer Name:

Employee Social Security Number:

(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)

If other family members in our care are also now covered by this plan, please indicate their names:

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.

Responsible Party Signature: *

Patient Name if different than above:

CLIENT INFORMATION

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

Client Name: *

DOB: *

Which provider(s) do you see? *

Which provider(s) do you see?

Does this insurance change affect any other accounts? *

Yes

No

If Yes:

Client Name:

DOB:

Which provider(s) do you see?

Client Name:

DOB:

Which provider(s) do you see?

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

New Insurance Company Name: *

Effective: *

Policy Holder's Name: *

Policy Holder's ID #: *

Policy Group #: *

800# for Mental Health/Eligibility/Verify Coverage: *

Policy Holder's Employer: *

Client's Relationship to Policy Holder: *

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.

Participant Signature *

Date *