Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client Intake Packet – Insurance/Self-Pay Welcome to Building Bridges Through Communication! We are delighted you’ve chosen us to support your journey. To help us get started, please review the simple guide below to find the best path for your needs. If You Use an HCS Waiver If you are utilizing an HCS Waiver, you do not need to fill out this intake packet. Simply contact your Case Manager to initiate services with BBTC. Using Your Insurance We are proudly in-network with the following providers: Blue Cross / Blue Shield Unitied Healthcare Aetna Better Health Medicaid Private Pay Options If your insurance provider is not listed above, we are happy to offer private pay options, Get a Quote: To receive our current rates, email admin@buildingbridgestherapy.org. The Packet: You are welcome to complete the intake packet either before or after you request these rates. Questions? Feel free to reach out to us at admin@buildingbridgestherapy.org. How To Start (Note: these are required before we can provide services.) Complete the Client Intake Packet in full. Provide a referral from your physician. Section 1: Patient Demographic Information Client's Name *FirstLastClient's Date of Birth *Client's Email *Client's Phone# *Client's Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeClient's Diagnosis *Reason for Referral *Section 2: Guardian InformationGuardian's Name *FirstLastGuardian's Phone# *Guardian's Email *Emergency Contact's Name *FirstLastContact's Phone# *Additional CommentsSection 3: Requested Services InformationServices Requested *STOTPTDIBHCounselingAre You Interested in Telehealth? *YESNOAvailability *How did you hear about BBTC? * Section 4: Insurance Information Does Client/Patient have Medicare? *YESNODoes Client/Patient have Medicaid? *YESNOPrimary Insurance Carrier *Blue Cross / Blue ShieldUnitied HealthcareAetna Better Health MedicaidName of Insured *FirstLastGroup Number *Policy Number *Member ID Number *Social Security Number *Does the Client/Patient have a secondary insurance/payor? *YESNOSecondary Insurance Carrier *Blue Cross / Blue ShieldUnitied HealthcareAetna Better Health MedicaidName of Insured *FirstLastGroup Number *Policy Number *Member ID Number *Social Security Number *Are there any other funding sources? *YESNOPlease explain below *Section 5: Referring Physician's Information Guardian's did Client/Patient PCP's Name *FirstLastPCP's Phone# *PCP's Fax# *PCP's Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Please upload a copy of the FRONT and BACK of your insurance card. (Note: File extensions allowed include: .png, .gif, .jpg) FRONT of Insurance Card FRONT of your insurance card. * Drag & Drop Files, Choose Files to Upload BACK of Insurance Card BACK of your insurance card. * Drag & Drop Files, Choose Files to Upload Submit
