Insurance Coverage Form

To learn of the cost per session based on your insurance coverage, please complete form below. Insurance plans do vary, and so it is always recommended to check with your insurance provider directly to inquire about “mental health benefits in a Telehealth setting”.

*Healing Hearts VA currently accepts carriers of Blue Cross Blue Shield/Anthem, Carefirst, Cigna, FEP BCBS, BCBS of Capital Area, Optum/United Healthcare, and Aetna insurance. The practice does not accept EAP.

*A diagnosis code will be assigned for those interested in using insurance.

Please submit an inquiry before filling out your insurance information - located under the “Contact Us” tab.

Client Name

First Name

Last Name

Phone Number*

Today's Date

YYYY

Reason for Insurance Benefit Check

Health Insurance Provider Name

Is this a Medicare or Medicaid plan?

Health Insurance Policy Number / Benefits Number*

Policy Holder Name

Date of Birth of Policy Holder

Date of Birth of Client (person who will be receiving counseling)

Mental/Behavioral Health Provider Number

Number is located on back of ID card. If no number listed, please list provider phone number on back of card for Provider Services.*

Policy Holder Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Address of Client

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Session

Clinician Interest

Insurance Disclaimer

I am aware that Healing Hearts VA will look into benefit information before meeting with a counselor, but it is the responsibility of the client to confirm benefits with their insurance provider directly to guarantee cost per session.

Online Practice*

I am aware that Healing Hearts VA is an online, remote practice, and that I will be meeting with a counselor virtually.

Insurance Form

Insurance Coverage Form

To learn of the cost per session based on your insurance coverage, please complete form below. Insurance plans do vary, and so it is always recommended to check with your insurance provider directly to inquire about “mental health benefits in a Telehealth setting”.

*Healing Hearts VA currently accepts carriers of Blue Cross Blue Shield/Anthem, Carefirst, Cigna, FEP BCBS, BCBS of Capital Area, Optum/United Healthcare, and Aetna insurance. The practice does not accept EAP.

*A diagnosis code will be assigned for those interested in using insurance.

Please submit an inquiry before filling out your insurance information - located under the “Contact Us” tab.

Healing Hearts VA, LLC

Virginia Online Mental Health Practice