This secure, encrypted form will be sent to Mindbridge's Insurance Processor/Scheduler. The two companies Teresa uses are Sondermind and Headway. Based on your Insurance, one of these companies will contact you for final processing.
Please enable JavaScript in your browser to complete this form.
Email
*
Phone
*
Legal Name on Insurance Card (or ID Card for Self Pay)
*
First
Last
Date of Birth (ex. MM/DD/YEAR)
*
Insurance Company
Aetna
Anthem
Apostrophe
BCBS
Bright
Care First
Cigna
Friday
Kaiser
Medical Mutual
Medicare
Optum
Oscar
Oxford
United Healthcare
Self-Pay
I am using Self-Pay, not Insurance.
Secure Submit
You can return to the homepage by clinking
HERE.