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CHS Pre-Intake Insurance Form
Securely submit your insurance information to determine your benefits in order to schedule an intake.
* Indicates required question
Name of Person Submitting Form
*
Your answer
Phone Number
*
We will use this number to contact you about setting up an appointment. If you prefer not to receive voicemail at this number, please notate.
Your answer
Client Name
*
Your answer
Client Date of Birth
*
MM
/
DD
/
YYYY
Insurance Company
*
Anthem- In Network
Husky A & B- In Network
Aetna- Out of Network
Cigna- Out of Network
Charter Oak- In Network
Yale Health Plan- Out of Network
Magellan- In Network
Medicare- Out of Network
Oxford- Out of Network
United- Out of Network
Tricare- In Network
Blue Cross/Blue Shield/Blue Care- In Network
Other:
Required
Insurance ID
*
Your answer
Primary Insurance Holder Name
*
Which family member is the insurance under?
Your answer
Primary Insurance Holder Date of Birth
*
MM
/
DD
/
YYYY
Insurance Information
Are you aware of any copay, deductible, or co-insurance for your insurance? If so, please explain below.
Your answer
Do you know which clinician you are assigned to?
Caitlin
Elaine
Joanne
Julia
Molly
Richard
Sarah
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