Insurance Submission Portal

ALL patients are asked to submit proof of mental health insurance coverage before the date of their scheduled appointment.

Please supply the office with a copy (front and back) of your active insurance card and Driver’s License before the date of your appointment by one of the following options:

1. If using a smartphone, take a picture and send the pictures VIA email of the front and back of your cards to: box1.jnmdpa@gmail.com

2. Fax a copy of the front and back of your cards to 817-545-9134 if you do not have email.

3. Bring a physical copy of your cards to our office located at 5017 Heritage Avenue, Colleyville, Texas, 76034 #102. Before the date of your appointment.

4. Submit a picture/file of the document online, you will need to send both sides of the card. See submission form.

Patient Contact Information

Name *

First

Last

E-mail *

Confirm Email

Phone *

Would you like to receive SMS (text) appointment reminders at the above phone number? (Please respond with STOP to any SMS (text) to cancel SMS (text) communication.) *

Yes
No. I do not want to get appointment reminders.

Driver License / Identification card

List DL number here (8 numbers following the DL on your Driver License) *

Font Of Driver License (Picture of front of card) *

Click or drag a file to this area to upload.

New Patient Insurance Information

I am a New Patient and I: *

DO Have Insurance
DO NOT Have Insurance

Website

Please understand that it is your responsibility to provide your doctor’s office proof of and time to verify the
active status of your health insurance policy 5 days prior to your office visit. If you are unable to do so, please understand that you will be expected to pay the full cash price for your visit at the window prior to your visit. Following an office visit, we will be happy to submit a claim on your behalf to your insurance carrier, with exception of Medicare. Of course, any funds recovered from your insurance claim will be applied to your account and you will receive any fee adjustments per your health insurance contract. Cash prices are as follows:

Please be prepared to pay the full cash price for your visit if you fail to supply proof of insurance before the date of my visit.

If you have any questions please call our office before the date of your appointment, extension #1.