Client Portal

Out-of-Network Insurance Verification Form

Schedule a Free Consult

The best way to find out if this approach is for you is to schedule a complimentary consultation. All counseling consults are 20-30 minutes long. Depending on availability, this consult may be held over the phone, via video, or in-person.

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COVID-19 Notice

We are committed to the health and safety of all our clients. We continue to offer our services both in-person and via video. In-person availability is limited and varies per provider. We practice social distancing, the use of face coverings and all areas are cleaned in between sessions. We also ask that all clients stay in their vehicles until their appointment time to further reduce the risk of transmission.

Please call the 800 number on your insurance card and complete this form with a customer service representative via telephone. It is important that you understand your insurance coverage.

Client Name

  • DOB:
  • SSN:  

Insured Name:

  • DOB:
  • SSN:

Insurance Company:

  • Insurance Phone Number:
  • Mental Health Insurance (may be different than health insurance):
  • Claims Address:
  • Client Insurance ID#:
  • Group #:

Counseling Services

1) “Do I have mental/behavioral health coverage?” □ YES □ NO

If YES, continue.

2) “Do I have Out-of-Network benefits?” □ YES □ NO

If YES, continue.

3) “Do I have an Out-of-Network deductible?” □ YES □ NO

If YES, “What is my out-of-network deductible?”

“How much of my out-of-network deductible has been met?”

4) “Please verify that the following services are covered under my policy? If YES, what percentage?”

In-Person Sessions:

  • Individual Therapy, 30 minutes (CPT Code 90832): □ YES □ NO _____%
  • Individual Therapy, 45 minutes (CPT Code 90834): □ YES □ NO _____%
  • Individual/Couples/Family Therapy, 60 minutes (CPT Code 90837): □ YES □ NO _____%
  • Family Therapy, without patient present (CPT CODE 90846): □ YES □ NO _____%
  • Family Therapy, with patient present (CPT CODE 90847): □ YES □ NO _____%
  • Group Therapy (CPT Code 90853): □ YES □ NO _____%
  • *Psychological and psycho-educational testing codes vary. Please speak to your provider.

Video Sessions:

  • Individual Therapy, 30 minutes (CPT Code 90832-95): □ YES □ NO _____%
  • Individual Therapy, 45 minutes (CPT Code 90834-95): □ YES □ NO _____%
  • Individual/Couples/Family Therapy, 60 minutes (CPT Code 90837-95): □ YES □ NO _____%
  • Family Therapy, without patient present (CPT CODE 90846-95): □ YES □ NO _____%
  • Family Therapy, with patient present (CPT CODE 90847-95): □ YES □ NO _____%
  • *Psychological/Psycho-educational testing codes vary. Please speak to your provider.

5) “Do I need an authorization to receive any of these services?” □ YES □ NO

If YES, “What is my authorization number?”
“How many sessions are authorized?”

6) “What forms do I need to submit for reimbursement?”

7) “Do you require the providers signature on the superbill?”

8) “What is the most efficient way to submit these forms?”


Download a PDF copy of this form by clicking here.

What Our Clients Say

"I knew from the moment I met her that she was different than some of the therapists I've had in the past. I didn't feel like a weirdo. She made me feel accepted and safe."

- Elizabeth S. (Google)

"Throughout this process, I have learned to forgive, accept, and manage what I can control."

- Katherine D. (Google)

"I tried counseling here and there in the past, and although each time was a step in the right direction, this time I've noticed an absolute change in my mindset and how I feel."

- Michelle T. (Google)

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Frequently Asked Questions

How do I schedule an appointment?

There are a few different ways to schedule an appointment with one of our wellness practitioners.
Please choose the most convenient option for you.

Do you accept my insurance?

HWP does not accept insurance. Managed care companies were created to “manage” and contain escalating health care costs. Their bottom line is to reduce costs and raise profits; it is not to increase the quality of care professionals provide or your quality of life. HWP is solution-focused on quality of life and personal goals.

What is your cancellation policy?

If you need to cancel or change your appointment, we ask you to inform your provider at least 24 hours in advance of your scheduled session start time. Your full session fee will be charged for missed appointments and cancellations received less than 24 hours in advance.

What forms of payment do you accept?

Cash, credit cards, and health savings (HSA) or flex spending account (FSA) cards that have a major credit card logo on it are all accepted forms of payment.