Benefit Verification

Benefit Verification Request

Please complete this form to submit a Benefit Verification Request to Collective Counseling Solutions. We will respond by email from benefits@collectivecounselingsolutions.com.

Please only submit requests for insurances where you have received an in-network effective date from our credentialing team.

Our team will set up a chart for your client upon verification. Do not add sessions to your calendar that you do not want CCS to bill. Any sessions added for insurance clients will be submitted.

You do not need a Google-based email address to submit this form.

Request

Request Details

Email * This form collects your email so CCS can respond to the request.

Therapist Name * Use the name on your CCS Simple Practice account. Group Practice Name If applicable.

Is this request for a new or existing client? *

New Client at CCS Existing CCS Client with New Insurance Existing CCS Client to Re-Verify

Is this request for a supervisee's client?

No, I will be providing direct services to this client. Yes, my supervisee will be providing services to this client.

When should CCS add this client to Simple Practice?

Add client immediately so therapist can begin billing them through CCS. Wait to add client until therapist confirms costs with the client.

Do you need a CCS Simple Practice account?

I need a CCS Simple Practice account. N/A

Account Setup

New Simple Practice Account Setup

If you need a CCS Simple Practice account, provide the email address you would like to use. If you already have a non-CCS Simple Practice account, use a different email.

Simple Practice Account Email

Are you pre-licensed and supervised by another member of the Collective?

Yes, I am pre-licensed and have a supervisor in the Collective. No, I am fully licensed.

Supervisor Name

Insurance

Insurance Company

Primary Insurance *

Client

Client Information

Insurance Member ID * Client Date of Birth * Month, day, year.

Client Legal First Name * Client Legal Last Name *

Client Phone Number * Client ZIP Code *

Is the client the primary insurance policy holder?

Yes, the client is the primary policy holder. No, someone else is the primary policy holder.

If the client is not the primary insurance policy holder, provide the policy holder's legal information as listed with the insurance company.

Policy Holder Legal First Name * Policy Holder Legal Last Name *

Policy Holder Date of Birth * Policy Holder Gender * Policy Holder Relationship *

Should this chart be set up as virtual only?

VIRTUAL ONLY I plan to see this client in person, too.

Anything else you want us to know?

Kaiser

Kaiser Member Email

Kaiser Member Email Address Kaiser requires CCS to email members PHQ-9 and GAD-7 screeners.

* Required fields