Evolve Ventures Technologies LLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

State you'll be taking sessions in:

(If different from the State you live in)

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How do you plan to pay?

Insurance: Are you the primary policyholder/subscriber on this insurance plan?

Yes, I am the policyholder/subscriber. No, someone else is the policyholder/subscriber. I won't be using Insurance to pay my sessions.

Insurance card upload

Upload a photo of your insurance card

Insurance: Your relationship to the policyholder/subscriber:

Self Spouse Child/dependent Parent/legal guardian Domestic partner Other Not Applicable - I'm not using insurance to pay.

Policyholder/subscriber full legal name, if different from client:

If not utilizing insurance type "NA" "na" or "N/A" for "Not Applicable".

Policyholder/subscriber date of birth, if different from client:

If not utilizing insurance type "NA" "na" or "N/A" for "Not Applicable".

Policyholder/subscriber sex at birth, if required for insurance verification:

If not utilizing insurance type "NA" "na" or "N/A" for "Not Applicable".

Insurance company name:

If not utilizing insurance type "NA" "na" or "N/A" for "Not Applicable".

Member ID:

If not utilizing insurance type "NA" "na" or "N/A" for "Not Applicable".

Group number:

If not utilizing insurance type "NA" "na" or "N/A" for "Not Applicable".

Plan type, if known:

If not utilizing insurance select "NA" "na" or "N/A" for "Not Applicable".

Is this insurance through an employer, parent, spouse, marketplace plan, MassHealth/Medicaid, Medicare, or other source?

If not utilizing insurance select "NA" "na" or "N/A" for "Not Applicable".

Do you have a PCP (Primary Care Physician/Dr.) listed or required by this plan?

If not utilizing insurance select "NA" "na" or "N/A" for "Not Applicable".

Yes No Unsure Not applicable

Primary Care Provider name, if known:

If not utilizing insurance type "NA" "na" or "N/A" for "Not Applicable".

Primary Care Provider phone number and email, if known:

Do you already have a referral or authorization for therapy?

If not utilizing insurance select "I'm not using insurance."

Yes Not yet, I've request one already though Unsure My plan doesn't require one. I've verified already. I'm not using insurance.

I understand that submitting insurance information allows Evolve Ventures Technologies LLC to begin an eligibility and benefits review. Verification of benefits is not a guarantee of payment. My insurance company makes the final determination of coverage, reimbursement, referral requirements, authorization requirements, and member responsibility.

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.