{"id":398,"date":"2023-06-23T16:11:44","date_gmt":"2023-06-23T16:11:44","guid":{"rendered":"https:\/\/neurogenesisflorida.com\/?page_id=398"},"modified":"2024-02-09T03:03:45","modified_gmt":"2024-02-09T03:03:45","slug":"insurance-form","status":"publish","type":"page","link":"https:\/\/neurogenesisflorida.com\/insurance-form\/","title":{"rendered":"Insurance Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"398\" class=\"elementor elementor-398\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1bd4b16 e-flex e-con-boxed e-con e-parent\" data-id=\"1bd4b16\" data-element_type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f196a70 elementor-widget elementor-widget-heading\" data-id=\"f196a70\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 18-04-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Insurance Form<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d5894e5 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"d5894e5\" 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.e-font-icon-svg{height:1em}.elementor-select-wrapper .select-caret-down-wrapper{position:absolute;top:50%;transform:translateY(-50%);inset-inline-end:10px;pointer-events:none;font-size:11px}.elementor-select-wrapper .select-caret-down-wrapper svg{display:unset;width:1em;aspect-ratio:unset;fill:currentColor}.elementor-select-wrapper .select-caret-down-wrapper i{font-size:19px;line-height:2}.elementor-select-wrapper.remove-before:before{content:\"\"!important}<\/style>\t\t<form class=\"elementor-form\" method=\"post\" name=\"Insurance form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"398\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"e24f78b\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_9ef7d70 elementor-col-100\">\n\t\t\t\t\t<h4 class=\"form-section-heading\">Service info<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d41f23d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d41f23d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tServices needed\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Psychotherapy\/Counseling\" id=\"form-field-field_d41f23d-0\" name=\"form_fields[field_d41f23d][]\"> <label for=\"form-field-field_d41f23d-0\">Psychotherapy\/Counseling<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Psychological Testing\/ADHD Assessment\" id=\"form-field-field_d41f23d-1\" name=\"form_fields[field_d41f23d][]\"> <label for=\"form-field-field_d41f23d-1\">Psychological Testing\/ADHD Assessment<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0567a69 elementor-col-100\">\n\t\t\t\t\t<p>Please note that neurofeedback services are self pay only and not covered by insurance<\/p>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1ad95ab elementor-col-100\">\n\t\t\t\t\t<h4 class=\"form-section-heading\">Patient's info<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_03859a1 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_03859a1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_03859a1]\" id=\"form-field-field_03859a1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_dae751e elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dae751e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_dae751e]\" id=\"form-field-field_dae751e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"xx\/xx\/xxxx\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_c21496e elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c21496e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_c21496e]\" id=\"form-field-field_c21496e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_792bd86 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_792bd86\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_792bd86]\" id=\"form-field-field_792bd86\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_da3bd45 elementor-col-100\">\n\t\t\t\t\t<h4 class=\"form-section-heading\">Policyholder's info (if different from patient)<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_30b32a5 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_30b32a5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_30b32a5]\" id=\"form-field-field_30b32a5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1055bff elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1055bff\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1055bff]\" id=\"form-field-field_1055bff\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_60f1248 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_60f1248\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_60f1248]\" id=\"form-field-field_60f1248\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1382bfb elementor-col-100\">\n\t\t\t\t\t<h4 class=\"form-section-heading\">Insurance info<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_83b8f57 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_83b8f57\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance carrier\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_83b8f57]\" id=\"form-field-field_83b8f57\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f84cf58 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f84cf58\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance member ID number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f84cf58]\" id=\"form-field-field_f84cf58\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_31d59e9 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_31d59e9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance carrier phone number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_31d59e9]\" id=\"form-field-field_31d59e9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ebab181 elementor-col-100\">\n\t\t\t\t\t<h4 class=\"form-section-heading\">Name of individual filling out this form<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5702733 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5702733\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5702733]\" id=\"form-field-field_5702733\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_98d615c elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_98d615c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_98d615c]\" id=\"form-field-field_98d615c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8355bcb elementor-col-100\">\n\t\t\t\t\t<h4 class=\"form-section-heading\">Insurance card<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_efc7f7c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_efc7f7c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhoto of front of insurance card\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_efc7f7c]\" id=\"form-field-field_efc7f7c\" class=\"elementor-field elementor-size-sm  elementor-upload-field\" required=\"required\" aria-required=\"true\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_3bfddca elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3bfddca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhoto of back of insurance card\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_3bfddca]\" id=\"form-field-field_3bfddca\" class=\"elementor-field elementor-size-sm  elementor-upload-field\" required=\"required\" aria-required=\"true\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text\">\n\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_36516f2]\" id=\"form-field-field_36516f2\" class=\"elementor-field elementor-size-sm \" style=\"display:none !important;\">\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-sm\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\" elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Insurance Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/pages\/398"}],"collection":[{"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/comments?post=398"}],"version-history":[{"count":100,"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/pages\/398\/revisions"}],"predecessor-version":[{"id":1428,"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/pages\/398\/revisions\/1428"}],"wp:attachment":[{"href":"https:\/\/neurogenesisflorida.com\/wp-json\/wp\/v2\/media?parent=398"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}