Payment and Insurance Registration Form

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Select your payment method*

Health Insurance

Private Pay

Insurance and Billing Pre-Authorization Registration Form

Health Insurance and Billing Pre-Authorization Registration Form

Please complete all required fields. Once completed your information will be submitted securely and verified to ensure your insurance is accepted by the provider including coverage and benefit details. If your provider is Out-of-Network, claims will be submitted on your behalf, but you will be responsible for the full rate at time of service. Any payable benefits will be reimbursed to the subscriber of the plan. You will receive quote of benefits and rates via email confirmation from our Billing Manager, Victoria House [email protected] so that you know your account is ready for services with the provider you have been assigned.

Are you a New Patient, Existing Patient or Private Pay

Referred by / Assigned Therapist Name (Unknown if not yet assigned)

Patient Name*

Patient Date of Birth

Address*

Phone*

Email*

Insurance*

Optum/ Medicare Plans

We are unable to accept Optum/Medicare plans in-network at this time. However, we can accept them as out-of-network. Please call our office to check for availability.

"Other" Insurance Name

Insurance Cardholder Name*

Cardholder Date of Birth*

Policy Number#*

Group Number # if applicable

Copay Amount

Deductible

Deductible Met?

Yes

Unsure (don't worry if you're not sure, this will be verified for you)

Relationship to Patient

Self

Spouse

Child

Patient Date of Birth

Attach image of your insurance card

Yes

Please upload an image of your Insurance Card here (FRONT):

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Please upload an image of your Insurance Card here (BACK):

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Do you have Secondary Insurance(Include active plans)

Do you have Secondary Insurance

Yes

No

Secondary Insurance Name

Policy ID#

Policy Holder's Name

Date of Birth
MM slash DD slash YYYY

Upload an image of Secondary Plan ID Card (if not already attached above):

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Do you have EAP Benefits

Do you have an EAP authorization or plan to use EAP benefits-please complete the info below so we can verify?

Yes

No

EAP Auth#

Number of Sessions Auth'd

Auth Effective Date

Auth Expiration Date

We accept EAP referrals from Optum EAP please provide your auth# and number of sessions you have been approved for.

Authorization

Signature of Responsible Party (use mouse or finger to sign)*

If an intake coordinator/representative completes
If an intake coordinator/representative completes this form on my behalf, I authorize them to sign with an 'X' on my behalf.

Today's Date*
MM slash DD slash YYYY

Name of Intake Representative Filling Out This Form
First

If someone else
Check this box, If someone else, besides the patient/responsible party, is completing this form and is financially responsible for any balance due, please add your contact info here:

Name of Responsible Party if other than Patient named above*
First Last

Address
Street Address City State ZIP Code

Phone

Email

Relationship with patient/client

Credit Card Authorization form

Credit Card Information

Please complete all required fields, including your credit card or checking account information. This is required to move forward with scheduling and ensures a smooth billing process. Your information will be securely submitted to our Billing Manager, Victoria House, and will only be used to create your StoredPay account. Once submitted, you will receive a separate confirmation email from [email protected] to authorize the use of your payment method for copays, deductibles, and private-pay balances per your rate agreement. ⚠️ Note: Your card will not be charged until services are rendered. However, submitting your payment method is required to verify financial responsibility and reserve your appointment.
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Name*
First Last
This field is hidden when viewing the form
Address*
Street Address City State ZIP Code

This field is hidden when viewing the form
Phone Number*
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Other Phone
This field is hidden when viewing the form
Email*

Select Credit Card or Account Checking Options:

CREDIT CARD

ACCOUNT CHECKING
Credit Card Information
Name as it appears on Card*
Card#*
Billing Zip Code for this Account*
Exp. Date*
Financial Responsibility & Release of Information Agreement (Signature Required)*
1) I authorize use of this form to convey my billing information to House Medical Billing Service; Victoria House, Billing Manager/Owner.
2) I authorize release of information to my insurance company (if applicable) for claims billing purposes.
3) I authorize insurance payments (if applicable) directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; you will be expected to cover the amount insurance would pay or the normal rate you would pay for attending your appointment.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.
I agree to the above 1 to 7 policies of Insight Wellness Center's practice and services they provide
Signature of Responsible Party (use mouse or finger to sign)*
Bank Account Information
Bank Account Name
Routing Number
Account Number
Financial Responsibility & Release of Information Agreement (Signature Required)*
1) I authorize use of this form to convey my billing information to House Medical Billing Service; Victoria House, Billing Manager/Owner.
2) I authorize release of information to my insurance company (if applicable) for claims billing purposes.
3) I authorize insurance payments (if applicable) directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; you will be expected to cover the amount insurance would pay or the normal rate you would pay for attending your appointment.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.
I agree to the above 1 to 7 policies of Insight Wellness Center's practice and services they provide
Signature of Responsible Party (use mouse or finger to sign)*
if you are filling this form
Check this box, if you are filling this form on behalf of someone else and you have the consent from the party in initiating this inquiry to sign on their behalf.
Full Name*
Phone*
Email*

If someone else, besides the patient, is completing this form and is financially responsible for any balance due, please add your contact info here:
Please direct any future billing questions to Victoria House, Billing Manager via email [email protected] Or Call (530) 474-6094
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Phone
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