CLIENT PAYMENT FORM

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New Submission

Updating Information

CLIENT INFORMATION

First Name *

Last Name *

Date of Birth *

Clinician Assigned to Client * Alexandra LecherAlexandra RovelloAlexandra SollazzoAmy AlberoAnnemarie CarpenterArielle KemplerAudra AntonielloBrittany KingCarli KingCarly CarboneCatherine van EyckChey JohnsonDaniela TrotmanDebbie StecklerElise McCandlessElisabeth DiDonatoEmma CianciJacqueline FidelmanJessica CunninghamJessica DesaiLuz SanabriaMartine BrunoMcKenzie WilliamsMataya RobertsonMegan YoungMelissa WeidnerNicole PradellaSiobhan BoyleSophie LindsaySymone McCullersThea Haley

PAYMENT OPTIONS

Please select a primary payment method:

Insurance Reimbursement (In-Network): This option may require a copayment at time of service.

Private Pay or Out-of-Network Insurance Reimbursement: This option requires full payment at time of service.

Please select the preferred method of payment for any and all Patient Responsibility portion of your session balance:

Credit/Debit Card: Please fill out Credit/Debit Card Section.

Paypal (Payment@ReviveCFW.com)

Venmo (@Revive-CenterForWellness)

CREDIT/DEBIT CARD INFORMATION

Type of Card:

AMEX

Mastercard

Visa

Other

Is this an HSA Card?

NoYesDon't Know

Name on Card

Card Number

Expiration

Security Code

Address of Cardholder

Address of Cardholder

Address of Cardholder

Address of Cardholder

City

City

State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

State/Province

Zip/Postal

Zip/Postal

INSURANCE INFORMATION

Insurance Carrier

Anthem (BCBS)AetnaBeacon Health OptionsCignaComPsychConnecticareFallonHarvard PilgrimHealthPartnersHumanaMagellanHusky (CT Medicaid)MagellanMassHealth (MA Medicaid)MedicareMeritainOptumOscarOxfordSunshine Health (FL Medicaid)TuftsUMRUnitedHealth (UHC)WellFleetOther

Provider Services Number (Back of Card)

Member ID

Insured's Relationship to Subscriber * SelfSpouseChildOtherLiving TogetherPartnersParentOther Care Provider

Member Name (on Record with Insurance, if different)

Member Gender (on Record with Insurance, if different) MaleFemaleOther

Subscriber's Full Name

Subscriber's Date of Birth

Using EAP?

NoYes

# Sessions

Authorization Number

EAP Manager

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*NOTE: Neither this form or any credit card information is stored on Revive’s website.  All forms are transmitted to Revive’s billing department and then immediately deleted.