Paramount Mental Health Counseling LLC

Benefits Verification Form

Complete this secure form so our office can review your behavioral health insurance benefits before scheduling.

Takes about 3–5 minutes Mobile friendly Insurance card upload

Client Information

Tell us who will be receiving services.

Client’s full name

Client’s date of birth

Phone number

Email address

Address the insurance company has on file

Primary Insured

Complete this section even when the client is the policyholder.

Primary insured’s full name

Primary insured’s date of birth

Relationship to client

Primary insured’s employer

Insurance Details

Use the information printed directly on the insurance card.

Benefits verification is an estimate and is not a guarantee of coverage or payment. Final responsibility is determined by the insurance plan.

Insurance company

Member ID

Group number

Provider Services or Behavioral Health phone number

Usually located on the back of the insurance card.

Preferred contact method

Best time to contact you

Questions or additional notes

Upload Insurance Card

Please upload clear images of both sides of the card.

↑ Front of insurance card Tap to choose an image or PDF ↑ Back of insurance card Tap to choose an image or PDF

Important: This design must be connected to a secure, HIPAA-appropriate submission and storage service before it is used to collect real client information.

Review & Authorize

Confirm the information below before submitting.

I authorize Paramount Mental Health Counseling LLC to contact my insurance company to obtain information about eligibility, benefits, deductibles, copayments, coinsurance, authorization requirements, and other behavioral health coverage information.

I understand that verification of benefits is not a guarantee of payment and that I may remain responsible for charges not covered by my insurance plan.

Typed signature

Date

Benefits Verification Form

Client Information

Primary Insured

Insurance Details

Upload Insurance Card

Review & Authorize

Paramount Mental Health Counseling, LLC

Practice Location: (Virtual Appointments Only)
Tallahassee, FL 32301

Contact Information: admin@paramountmhc.com
(850) 792-7502

Client Information

Primary Insured

Insurance Details

Upload Insurance Card

Review & Authorize

Paramount Mental Health Counseling, LLC

Practice Location: (Virtual Appointments Only)Tallahassee, FL 32301

Contact Information: admin@paramountmhc.com(850) 792-7502

Practice Location: (Virtual Appointments Only)
Tallahassee, FL 32301

Contact Information: admin@paramountmhc.com
(850) 792-7502