Tracking Test – Form 63. | Improving Lives Counseling Services

Email

This field is for validation purposes and should be left unchanged.

Client's Name(Required)

Phone(Required)

Email(Required)

Name of DHS Case Worker(Required)

Phone Number of DHS Case Worker(Required)

County of current DHS case(Required)

Reason for Seeking Services(Required)

You may be as broad or specific as you choose

City/Town of Residence(Required)

Preferred Clinicians Name(Required)

Groups (if you select a group that is not currently active we will let you know if it becomes available)

Select ALL insurance coverage that applies to this client – If you are completing this form on a computer hold ctrl or command to select more than one insurance(Required)

EAP Plan Name(Required)

EAP Phone Number(Required)

EAP Authorization or Referral Number(Required)

Front and Back of All Health Insurance Cards Except Medicaid – Failure to include pictures of ALL insurance cards may delay services.(Required)

Drop files here or

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

If cards are not provided and you incur charges that we are unable to submit to your insurance, you will be responsible for all charges not covered. If you are completing this form on your phone you can take a picture with your camera.

SoonerCare/Medicaid ID or Social Security Number(Required)

If you do not know the SooneCare/Medicaid ID Number you must enter the client’s social security number so we can look up the ID information.

MEDICAID/SoonerSelect
Self-Pay/Sliding Scale
EAP (Employee Assistance Program)
Aetna
Aetna Coventry
Alliance Coal
Allied National
AmBetter
BlueCross Blue Shield
ChampVA
Cigna Health and Life Insurance Co.
Edison Health Solutions
GPA
Group Benefit Services (GBS)
Health Smart
Healthcare Highways
HealthCare Solutions Group
HealthChoice
HealthScope
HealthSmart
HealthSmart Benefit Solutions
Humana Military
HumanaChoice PPO
Medica
Medicare
Meritain Health
OPTUM VA
The Kempton Group
Tricare East
UMR – Wausau/UHIS
United Health Care/United Behavioral Health
WebTPA

Tracking Test – Form 63.

Insurance ID’s and Cards ga4test form

Groups (if you select a group that is not currently active we will let you know if it becomes available)