Insurance Processing Request Form

If you have a health insurance policy, it may provide some coverage for mental health treatment. MyCounselor will provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of your fees. A receipt will be provided for you to submit to your insurance if you so desire or for a fee of $5 MCO will process your claim using an independent medical claims processor. However, MCO has no control over the amount of reimbursement you may or may not receive. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes MCO must provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, MCO has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. MCO will provide you with a copy of any report we submit if you request it.

I would like MCO to submit insurance claims on my behalf.*
I understand I am requesting MCO to submit claims to my insurance on my behalf and there is a $5.00 fee for each claim MCO to submits.
Patient Name*
First Last
Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Patient Gender*
Images of Insurance Card (Front & Back)*
Drop files here or
Date*
Date Format: MM slash DD slash YYYY
Subscriber Name*
Person who is primary on the insurance policy
First Last
Subscriber Birth Date*
Date Format: MM slash DD slash YYYY
Subscriber Gender*
Contact Phone Number*
Name of Client or Guarantor *
First Last
Email*