Insurance Form

Message

The selected event does not exist !
The selected event does not exist !
The selected event does not exist !
The selected event does not exist !

Insurance We Honor

In Network Insurance

Advanced Health Systems (AHS)
Aetna
Blue Cross Blue Shield of Mississippi
Blue Cross Blue Shield Out of State Plans
Cigna Behavioral Health
ComPsych
First Choice Health Plan of Mississippi
First Health
Galaxy Health Network

GEHA
Life Synch
Magellan Behavioral Health
Mississippi Physicians Care Network
PPOUSA
Three Rivers Provider Network
United Behavioral Health (UBH)
USA Managed Care Network
Value Options

A Bridge to Recovery is in the process of becoming providers for a number of other companies so if your carrier is not listed it does not mean we do not accept your insurance. A number of carriers will do what is called a "Single Case Agreement" which allows a "Out of Network" provider to see a client and will pay the in network rate.

Insurance Coverage Form

Use the following secure form to send us information about your insurance coverage.
NOTE: Fields marked with an asterisk are required to verify coverage.

YOUR INFORMATION (not necessarily the prospective patient)
*Name:
*Email:
Address:
City:
State:
Zip:
Phone (home):
Relation:
Services - Please tell us what services you would like us to check for.	IOP Individual Mental Health Substance Abuse

PROSPECTIVE PATIENT
*Name:
*Address:
*City:
*State:
*Zip:
*Phone (home):
Phone (business):
*Date of Birth:
*Social Security #:
Comments:
Please let us know about any special circumstances and how we should contact you and/or the prospective patient.

INSURANCE COMPANY
*Insurance Company:
*Insurance Phone #:
*Insurance Policy #:
*Insurance Group #:
Plan:
Effective Date:

INSURED PARTY
*Insured Name:
*Relation to Patient:
*Social Security #:
*Date of Birth:
*Employer:
Still Employed:
Length:
Term Date:

To Which Loaction Should This Form Be Sent?	Southaven Ridgeland

I am providing this information for use only by A Bridge to Recovery. Any information given will be kept private and confidential.

Insurance We Honor

Insurance Coverage Form

YOUR INFORMATION (not necessarily the prospective patient)

PROSPECTIVE PATIENT

INSURANCE COMPANY

INSURED PARTY