Let’s work together Name * First Name Last Name Date of birth * MM DD YYYY Are you the subscriber? If not, please list the subscriber's full name. * Email * Phone (We will not call unless your email address doesn't work) (###) ### #### Who is your health insurance carrier? * Aetna Blue Cross Blue Shield Harvard Pilgrim Health Care United HealthCare Tufts (Public/Private/Commercial) Other Member ID * Policy Start Date MM DD YYYY Policy End Date MM DD YYYY Do you have a copay or deductible that applies to standard out-patient mental health services on your policy? * Yes No I don't know If you are uncertain whether a copay or deductible applies to standard outpatient mental health services, please contact your insurance carrier's Member Services. They can provide the most up-to-date and accurate information regarding your policy. While we can verify policy details based on reports from Provider Services, this information may not always be accurate. If services are denied for any reason, the member may be responsible for the full session rate. Our standard rates are $200 for an intake session and $175 for a standard session. For the most reliable coverage details, we recommend reaching out to your insurance provider directly. * I have read and understand Any questions or concerns? Thank you! An AVIV team member will verify this policy and send you an email with the information we receive! We try to get this done ASAP. If you have any questions while waiting on this verification, feel free to reach out to Contact@Aviv.Life!
