Insurance Verification Request

Rumi’s Den Marriage & Family Therapy Insurance Verification Request

Complete this form so we can verify your mental health eligibility and benefits. You will need your insurance card and a photo ID.

Your details

Full name *

Phone

Directions

You may use your phone, tablet or computer to complete this form.

Before you start

To get started, you'll need your insurance card and photo ID.

Once you've finished filling out the form, you'll need to take photos of both cards and upload them before you submit.

When you have your insurance card and ID in hand, click Next to continue.

Contact Information

Street address *

Street address line 2

City *

State / Province *

Postal / Zip code *

Who's your doctor / therapist / provider? *

Which of the following applies? *

I want in person appointments I prefer Telehealth (over video) I'm open to either in person or telehealth

Insurance Information

About using insurance

Each provider has different circumstances when it comes to insurance. Some don’t accept insurance, some accept a few plans, and some accept many.We have a limited number of providers who are fully credentialed with insurance. This means if you wish to utilize your insurance, you may be added to a wait list until one of our providers has an opening for an insurance-based client. The wait could be a month or longer. If you are in a crisis or need urgent care, we recommend paying out-of-pocket until we have an opening or seek out other in-network providers in your area.

Insurer *

ID number *

Insurance card issue date (if known)

Date of birth *

Attach a copy of your insurance ID card. *

Front of the card. A clear phone photo is fine.

JPG, PNG, HEIC, WEBP or PDF, up to 10 MB. A clear photo from your phone is fine.

Attach a copy of your state issued DL / ID card. *

JPG, PNG, HEIC, WEBP or PDF, up to 10 MB. A clear photo from your phone is fine.

Do you receive health insurance through Medicaid / Medi-Cal? *

Yes No

If yes: Social Security Number (SSN)

Only required for Medicaid / Medi-Cal beneficiaries so that benefits can be processed accurately.

Authorization

Submission of this form authorizes us to verify your mental health eligibility and benefits, including any copay and deductible. Results are typically available within one to two business days. If you have any questions, contact your provider or send us a message.

Comments

Date *

Signature *

Type your full legal name to sign electronically.

Typing your name acts as your electronic signature.

Your answers are sent privately to your care team.