Please be sure to complete ALL REQUIRED fields; any omitted information will delay the submission and processing of insurance claims. Registration and insurance claims submission is not a guaranteed of coverage. Our practice has providers that are Participating and Non-Participating with private and state insurance. Failure to submit insurance information in a timely manner may result in patient's responsibility of the full fee at time of appointment(s). PLEASE BE SURE THE IMAGE OF INSURANCE CARD AND PHOTO ID INCLUDE NO BACKGROUND OR THE FILE WILL BE AUTOMATICALLY DELETED.
Patient's Info (if different from insured's): *REQUIRED IF DIFFERENT FROM INSURED
PSYCHOTHERAPY SERVICES GROUP _ 358 Montauk Avenue, New London, CT 06320 US 860.443.1396
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