Insurance Verification Form

We know that contacting your insurance company to gain an understanding of your benefits is time-consuming and often frustrating. We would be happy to courtesy-verify your benefits so you clearly understand your coverage before starting treatment.

 
Complete the form below, and we will be in touch with you ASAP to inform you of your coverage and financial responsibilities.
[[[["field58","contains","John P. Carnesecchi, LCSW, CEAP"]],[["email_to",null,"john@gatewaytosolutions.org"],["email_to",null,"gtSverify@gmail.com"]],"or"],[[["field58","contains","John A. Mendiola, MD (Infusions ONLY, not therapy)"]],[["email_to",null,"jamendiolamd@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[[]],[],"and"],[[["field58","contains","Doria Miller, LMSW"]],[["email_to",null,"doriacmiller@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Madeline Weinfeld"]],[["email_to",null,"madelineweinfeld@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Mariam Hager, LMSW"]],[["email_to",null,"mariamhager@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Christine Menna, LMSW"]],[["email_to",null,"christinemenna11@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Caroline Grace Brown, LMSW"]],[["email_to",null,"carolinegbrown26@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Antoinette Bonafede, LCSW"]],[["email_to",null,"antoinette.bonafede27@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field44","equal_to","I am an existing client"]],[["show_fields","field46"]],"and"],[[["field53","contains","Yes, I have a secondary insurance policy"]],[["show_fields","field48,field49,field50,field51,field52,field54"]],"and"],[[["field23","equal_to","Not Listed"]],[["email_to",null,"nyfn17@gmail.com"]],"and"],[[["field58","contains","Christina Bradley, MS. Ed."]],[["email_to",null,"christinabradley.gts@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Danielle Dellaquila, LMSW, CBT, DBT"]],[["email_to",null,"Danielledellaquila.gts@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Jamie Downie"]],[["email_to",null,"JamieDownie.gts@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Debra"]],[["email_to",null,"gtSverify@gmail.com"]],"and"],[[["field58","contains","Mandolin"]],[["email_to",null,"gtSverify@gmail.com"],["email_to",null,"Mandolinmoody.contact@gmail.com"]],"and"],[[["field58","contains","Valerie"]],[["email_to",null,"Valeriekowalski17@gmail.com"],["email_to",null,"gtSverify@gmail.com"]],"and"]]
1 Step 1
Are you an existing client of Gateway to Solutions? *
If you are an existing client, who is your clinician? *Clinician's full name
First Name *
Last Name *
Date of Birth ( month ) *
Date *
Year *
Address 1 *
Address 2
City
State/Province *
Zip/Postal Code *
Country *
Phone Number
Do you have an HRA, FSA, HSA, or other health savings account?
Insurance Company *
Member ID number * (No Special Characters)
Group # (No Special Characters)
Insurance Company Phone Number *
Front of Insurance Card *Upload snapshot of the FRONT of your insurance card. (Only JPG and PNG Files under 6MB)
cloud_uploadUpload Front of Card
Back of Insurance Card *Upload snapshot of the BACK of your insurance card. (Only JPG and PNG Files under 6MB)
cloud_uploadUpload Back of Card
Do you have a secondary insurance policy? *
Secondary Insurance Company *
Secondary Member ID number *
Secondary Group #
Secondary Insurance Company Phone Number *
Front of Secondary Insurance Card *Upload snapshot of the FRONT of your insurance card. (Only JPG and PNG Files under 6MB)
cloud_uploadUpload Front of Card
Back of Secondary Insurance Card *Upload snapshot of the BACK of your insurance card. (Only JPG and PNG Files under 6MB)
cloud_uploadUpload Back of Card
Comments/Questions *
0 /
Which provider are you interested in working with to help reach your goal?
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