Insurance Verification

Novell and Novell Counseling security certificate New Client Insurance Verification Online Form

 

 

Welcome to Novell & Novell!

At Novell & Novell, we strive to assure that you receive excellent services throughout your time with us. We believe that all our clients deserve to receive the highest standard of care, and your privacy is of utmost importance to us. Therefore, we are committed to protecting your personal, insurance and medical information that has been entrusted to us. Please be assured that any form you fill out on our site is encrypted to protect your privacy. If needed, additional scanned information may be securely sent via our  Send An Attachment page. We look forward to serving you. Thank you for choosing us!

Client Information:
Client Name (required):

If client is underage: Parent or Guardian Name:

If Guardian, Relationship to Client:

Your Email Address (required)

Home Telephone Number:

Cell Telephone Number:

Work Telephone Number:

Date of Birth:

Social Security Number (required):

Address (required):

City (required):

Zip Code (required):

Treatment Information
Reason for treatment (required) Note: If there is a court order for counseling services, please
indicate above and provide us with a copy of the court order:

Who referred you to us:

Preferences (Days, times, gender of therapist, types of service):

Primary Insurance Information
Name of Insurance Co.:


Provider’s (Services/Mental Health/Behavioral Health) Phone Number:

Authorization Number:

Subscriber ID:

Subscriber Name:

If not client, specify relationship to client:

Date of Birth:

Social Security Number:

Secondary Insurance Information
Name of Secondary Insurance Co.:


Secondary Provider’s (Services/Mental Health/Behavioral Health) Phone Number:

Authorization Number:

Subscriber ID:

Subscriber Name:

If not client, specify relationship to client:

Date of Birth:

Social Security Number:

Additional Comments or Concerns



captcha Input Security Code at left:

Confidentiality of Emails
Novell and Novell is committed to protecting your personal, insurance and medical information that has been entrusted to us.  Please be assured that any form you fill out on our site is encrypted to protect your privacy.  We look forward to serving you.

Novell and Novell Counseling security certificate