Client & Medical Insurance Info

We accept commercial plans from Aetna, Cigna, Florida Blue, Oscar Health, United Healthcare, Oxford, Quest Behavioral Health, UBH General, & Carelon Behavioral Health. For out-of-network coverage, superbills are available for reimbursement.

Name

First Name

Last Name

Phone

(###)

###

####

Country & State of Residence

Insurance Provider Name

Member ID Number

Group Number

If no Group Number is listed on your insurance card, please leave this field blank.

Policyholder’s Name

If the insurance is not in the client’s name

Policyholder’s Date of Birth

I authorize Dr. Derek Israel and his staff to verify my insurance benefits with my insurance provider before my session.

I authorize