Request appointment | Moonstone Counseling PLLC

Request an appointment

Payment method

How do you plan to pay? Providing insurance details now helps us verify coverage in advance but is optional. We are In Network with: BCBS PPO, United Healthcare/Optum/UMR, Aetna, Baylor Scott and White, Traditional Medicare, Some Medicare Advantage Plans, Curative, Sendero. We are no longer in network with Cigna.

Insurance Name and Member ID Number.

Please put N/A if you do not plan to use insurance. Please make sure to include which type of insurance it is, for example BCBS or Aetna.

Insurance card upload

Upload a photo of your insurance card

Legal Name of Main Policy Holder if Different from Client

We only need this if you would like us to verify or use your insurance benefits.

Date of Birth for Main Policy holder If Different from Client

We only need this if you would like us to verify or use your insurance benefits.

Main Policy Holder Address If Different from Client

We only need this if you would like us to verify or use your insurance benefits.

Sex

We will only use this information for insurance claims filing and benefits verification checks. We will make sure your gender identity is respected.

Male Female

Consents

I consent to having Moonstone Counseling add my information to their Electronic Health Record I understand that it is my responsibility to complete the requested documents and consents prior to the requested appointment. I understand that Moonstone Counseling will attempt to verify insurance as a courtesy but cannot take responsibility if insurance payers provide inaccurate information. I consent to Moonstone Counseling contacting me via Email or Phone to verify insurance and payment details when needed.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.