Thank you so much for your interest in Life Skills Resource Group. In order to best serve we would like to provide the service of checking on your Insurance and how your benefits can work with LSRG.

Please note the ONLY Insurance company we choose to be In Network Providers for is Cigna Behavioral Health. Many people have excellent Out of Network Plans and we can creatively work with most to serve your needs.

If you choose to go with an In Network Provider after we have provided you the information we are happy to review you In Network Provider list and make suggestions.

By providing this information you are authorizing a Life Skills Resource Group representative to contact your insurance on your behalf.

Contact Us
	Name of patient as it appears on insurance card:
	Patient email address:
	Patient Phone Number:
	Patient DOB:
	Insurance ID#:
	Group #:
	Insured's name (this is person employed by company that provides the insurance):
	Insured DOB:
	Insured ID#:
	Insured Social Security Number if Insurance plan has a separate phone number for Substance abuse and Mental Health Treatment:
	Name of Employer (who provides insurance):
	Insurance Company:
	Mailing address for Insured:
	Phone number for Insured:
	Customer service phone number on back of insurance card:
	Phone number for Mental Health Service if there is separate number:
	May we acquire Pre-Certification for your visit?		yes no
	Counselor who phoned / emailed you		please select Cindy S. Fabico, MA Yolanda Brailey, MA Carma Kuhn Maribel Nieves, MA Angie Moates, MA Dominique Danielle Barritt, MA Jean Austin-Danner, MSW, LCSW Jessica Stage, MSW Kim Murphy, MS Amy Smith, MS
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