Check your Insurance Coverage. Name * First Name Last Name Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * What is the name of your health insurance provider? * Please provide us with the name of your insurance provider name and plan. Which can be found on the front of your insurance card. Member ID: * Please provide us with your member ID this can be found on the front of your insurance card. Group Plan * Please provide us with the group plan number which can be found on the front of your insurance card. If you do not have a group plan put none. Insurance Provider Phone Number * Provider phone number can be found on the back of your insurance card. (###) ### #### Message Please provide us with any other information you wish to share. By checking this box I agree to allow Jennifer L. Hillier and employee's of Mending Hearts Counseling to check and verify my insurance coverage for counseling. I understand Jennifer Hillier or employees of Mending Hearts Counseling is not responsible for any misinformation about your insurance provided by your provider. I understand that insurance coverages are limited and require medical necessities, and I am fully responsible for any expenses not covered by my insurances. I agree Thank you! Currently accepting BCBS, Cigna, Molina Health Care, and United Health Care.
