Insurance Agreement

Please complete this form if you are using your insurance (i.e. BCBS, UBH, Medicare) to pay for services. If you have Medicaid or are self paying for services, this form is not required. Most 3rd party payors (for example, insurance companies), require FCS to release certain information about diagnosis, type/place of service rendered, dates of service, and possibly other information. Some payors require a treatment plan and/or periodic review of services being provided. If you expect an insurance company to pay for your services, please provide the following information:

Name(Required)

First Last

Email(Required)

Phone(Required)

Primary Insurance

Primary Insurance Company

Insurance Phone Number

Group/Policy Number(s):

Primary Insurance Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Insured Person's Employer

Insured's Date of Birth

Insured's SSN

Secondary Insurance

Secondary Insurance Company (if applicable)

Insurance Phone Number

Group Policy Number(s)

Secondary Insurance Provider Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Insured Person's Employer

Insured's Date of Birth

Insured's SSN

Insurance Deductible

Your insurance MAY have a deductible that must be met before insurance will pay for your services. Please provide the following information:

Annual Deductible Amount:

Date Your Deductible Resets (often January 1st ):

Amount Paid Toward Deductible Already This Year:

Copayments are required at the time of service. Please enter that information below:

Co-Payment Amount

If your insurance company refuses payment, FCS will resubmit the claims for payment. If the insurance company continues to refuse payment for any reason, you will be responsible for payment for professional services. If you have trouble affording the balance owed, our billing department will work with you to make payment arrangements.