Call Us at 713-365-0700 or Make an Appointment

Insurance Verification Form

For new clients and current clients.

We like to verify your insurance at least 3 days (72 hours) prior to your appointment. This allows us to know what your portion is before you come in so that there are no surprises.

If you are a current client and your insurance has changed, you may input your information for us to reverify.

If you will be using an EAP (Employee Assistance Program) we will still need your insurance information as well as your EAP Authorization information PRIOR to you appointment. If we do not receive your EAP Authorization number or your Insurance information before your appointment, you will be responsible for the cash price of the session. Please call us with any questions. (713) 365-0700 x-302.

Please fill out all sections of the form.

Thank you so much for all you do!
~Renewing Hope Staff~

Client Name *

Date of Birth *

Month

Day

Year

Postal Address (Street, City, State, Zip Code) *

Type in address, for example: 11999 Katy Freeway Houston, TX 77079

Phone Number *

Insurance Company *

Name of Primary on Insurance Plan *

Primary Person's Date of Birth

Month

Day

Year

Insurance ID # *

Insurance Group # *

Insurance Company Mental Health Phone Number *

If using an EAP (Employee Assistance Program) - List the Name of the Company

EAP Company Phone Number

Name of person that the EAP is listed under.

EAP Authorization Number

Number of EAP of Session's Authorized

Start Date & End Date of EAP Authorization

Therapists Name *

Date Appointment Scheduled For

Month

Day

Year

Leave this field blank

Insurance Verification Form

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Insurance Verification Form

Get Driving Directions

Questions? Contact Us

We Specialize in