Supportive Advice, LLC. | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

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Address

Enter your full address including any apartment numbers if applicable

Administrative

Inquiry reason

Let us know how we can help

Referral source

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Billing & Payment

Payment method

How do you plan to pay?

Insurance Provider

Medical Mutual United Healthcare Anthem Blue Cross and Blue Shield Ohio Anthem EAP Aetna Carelon Behavioral Health Quest Behavioral Health Cigna I do not plan to use insurance - I will pay out of pocket

Insurance card upload

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Member ID

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Group ID

Enter the Group ID as listed on your insurance card or type NA if you plan to pay out of pocket for services

Plan ID

Enter plain ID as listed on your insurance card or type NA if you plan to pay out of pocket for services

Co-pay or Coinsurance

Please enter the copay listed in your benefit packet or insurance card or type NA if you plan to pay out of pocket for services

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.