Insurance Form

Service info

Services needed

Psychotherapy/Counseling Psychological Testing/ADHD Assessment

Please note that neurofeedback services are self pay only and not covered by insurance

Patient's info

First name

Last name

Date of birth

Email

Phone

Policyholder's info (if different from patient)

First name

Last name

Date of birth

Insurance info

Insurance carrier

Insurance member ID number

Insurance carrier phone number

Name of individual filling out this form

First name

Last name

Insurance card

Photo of front of insurance card

Photo of back of insurance card

PHONE: (407) 790-4101

© NEUROGENESIS CENTER OF FLORIDA

253 North Orlando Ave, Suite 202, Maitland, FL 32751