Mental Health Counseling Insurance Reimbursement Form
Client Information
Full Name
Date of Birth
Phone Number
Address
Insurance Information
Insurance Company
Policy Number
Group Number
Subscriber Name
Subscriber Date of Birth
Provider Information
Provider Name
Provider NPI
Provider Phone
Provider Address
Session Information
Date of Service
CPT Code
Diagnosis Code
Session Fee
Amount Paid by Client
Session Notes
Signature
Signature
Date