Payment Insurance & Forms

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Some insurance plans will only allow you to see providers who are part of their network. To determine your benefits and coverage, you should contact the Mental Health/Substance Abuse number on the back of your insurance card. This call will likely connect you with a customer service representative at the insurance company. They may ask you for the CPT or procedure code related to the treatment you are seeking. The CPT codes are 90791 for an initial evaluation and 90834 for individual therapy.

Outpatient Psychotherapy Insurance

  1. What are my mental health benefits?
  2. Do I have an out-of-network benefit?
  3. Do I have a deductible, and what is it (in network vs. out of network)?
  4. How much of my deductible has been met to date?
  5. Do I have a co-pay or co-insurance amount, and what is it (in network vs. out of network)?
  6. Do I have an out-of-pocket maximum, and what is it (in network vs. out of network)?
  7. Is there a limit to the number of visits covered per year (in network vs. out of network)?
  8. If so, is that a calendar year or benefit year?
  9. How many of the allotted visits have been used to date?
  10. What kind of authorization do I need to obtain in order to start treatment (in network vs. out of network)?
  11. If I pay for any procedure out of my own pocket, how do I obtain reimbursement for doing so?

For your convenience, you may prepare these forms in advance of your first appointment. Your web browser may not support PDF forms fill-in. For the registration form, download it completely to your computer and open it in Acrobat. Fill it in, print and sign it. The other forms simply need a signature. So simply print them and sign. You may then bring the forms with you to your first meeting.

In-Network Provider
  • Blue Cross Blue Shield, Tufts, Harvard Pilgrim Healthcare, Medicare
Out of Network
  • Provider for plans with out of network benefits
Self-Pay