Benefit Estimate

Benefit Estimate Request

Please complete this form to submit a Benefit Estimate 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.

Please email benefits@collectivecounselingsolutions.com if you have any questions or need to provide additional context about your form submission.

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 Only applicable to groups with two or more people. If you are a solo practitioner, please leave this field blank.

Is this request for a new or existing client? *

New Client at CCS Client does not currently have a chart set up in CCS Simple Practice. Existing CCS Client with New Insurance Client does currently have a chart set up in CCS Simple Practice. Existing CCS Client to Re-Verify Client does currently have a chart set up in CCS Simple Practice.

Will services be provided by a licensed or pre-licensed clinician?

Services will be provided by a licensed clinician. Services will be provided by a pre-licensed clinician.

Supervisor Name *

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.

Insurance

Insurance Company

Primary Insurance * Insurance Card Image Optional. Upload a picture or PDF of the client's insurance card if you have one.

EAP

EAP Request

Is this an EAP request?

No Yes

Type of EAP Plan * EAP Authorization Code *

EAP Date Range * Number of Sessions Approved for EAP *

EAP Member ID If different from regular member ID.

Client

Client Information

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

Client Legal First Name * Client Legal Last Name *

Client Email *

Client Phone Number * Client ZIP Code *

Client Gender * Client Street Address * Used for SimplePractice chart setup.

Should this chart be set up as virtual only?

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

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 *

* Required fields