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1130 SW Morrison St., Ste 417                          
Portland, OR 97205                          
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Your insurance will need to be verified prior to your first session

Contracted provider with:
•    Crime Victims Compensation Program
•    Family Care           
•    Kaiser Permanente         
•    Moda Health
•    OHP       
•    Regence BlueCross BlueShield  

Out-of-network provider with:
•    Aetna
•    Health Net
•    PacifiCare Behavioral Health
•    PacificSource
•    Providence
•    United Health Care
•    Others

During our initial phone conversation I will ask you to provide me with the following information:
•    Client's full name*
•    Client's date of birth*
•    Client's insurance company
•    Client’s insurance company phone number (from the back of the card)
•    Client's ID/Group/Policy number(s)
•    Client's employer*
•    Client's address
•    Client's phone number

For these categories, if the primary person insured on the policy is someone other than the client, please provide
both the client's information as well as that of the primary person insured.