Insurance Information Form - Light On Anxiety

Please note we are only in network with BCBS of IL PPO and AETNA. Please verify your insurance benefits by calling your insurance company directly. We ask that you do this to verify that your mental health benefits are covered by Blue Cross Blue Shield PPO or AETNA and not contracted through another provider. If your mental health benefits aren’t covered by insurance BCBS PPO or AETNA, we are still happy to work with you at the private pay rate and provide you with a super bill for possible reimbursement from your insurance company.

Name of Client*

* Please note: If you are a new client who has just filled out the intake form with your insurance you do not need to fill out the insurance update form.
Client Date of Birth*
Name of Policy Holder

*If different from client
Policy Holder Date of Birth

*If different from client
Insurance Company**
Member ID including 3 letter prefix*
Group ID*
Address of Policy Holder*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please upload a picture of the front of your insurance card*
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
Please upload a picture of the back of your insurance card*
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
What date did your new policy become active?*
MM slash DD slash YYYY