Deborah Lyman: Insurance Form

Deborah Lyman

LCSW

NOTE: Please make a copy of the front and back of your insurance card(s) and email the images to Deborah Lyman HERE.

Insurance Authorization

Insurance Form: Your Name *

First

Last

Middle Initial

Middle

Mailing Address *

(Street & Number or P.O.)

City *

State *

ZIP *

Home Phone *

May we leave a message? *

Other Phone *

May we leave a message? *

* Email Address *

Date of Birth *

PRIMARY Insurance Company Name *

Policyholder Name

(if different than client)

Policyholder Employer Name *

Date of Birth *

Insurance Identification # *

Group # *

SECONDARY Insurance Company Name

Policyholder Name

(if different than client)

Policyholder Employer Name

Date of Birth

Insurance Identification #

Group #

Deborah Lyman, LCSW, has my permission to communicate with my insurance company and to provide information necessary for the purposes of obtaining authorization for services, provision of services and coordination of care. Deborah Lyman, LCSW, or the billing service contracted with Deborah Lyman, LCSW, has my permission to bill my insurance company and to provide necessary information for the purposes of obtaining authorization for services, benefits information and payment.

Client's Name (as Signature) *

Date *

Comment