Release to Bill Insurance for Intakes

Please Note: You must complete one Release to Bill Insurance for each client meeting with a Larch therapist. A couple file is considered a separate client. Once you complete the form for one family member, please return to this page to complete any additional forms.

Instagram
This field is for validation purposes and should be left unchanged.
Fees & Insurance Policy – Please Read and Accept our Terms

Insurance

We are private pay providers, and are not In-Network or contract with any insurance companies. Although we understand that for some billing insurance is necessary, we believe there are many benefits to not billing insurance. For example, most insurance companies want to dictate how counseling is to be conducted, and what types of counseling will be covered, often denying certain types of couple and family work, and requiring a diagnosis for reimbursement. We believe that counseling is more effective if it is controlled by the counselor and client, rather than being dictated by a third party. Another benefit to not taking insurance is we can spend more time providing care to the people we work with, instead of spending hours completing all the paperwork and figure out the requirements of each insurance company.

**Out of Network Reimbursement

Sometimes insurance companies reimburse for Out of Network Providers for some types of services. Because of this, we are happy to submit these claims for you, but do not tailor our work towards insurance companies and reimbursement for the cost of counseling. We often recommend people seek treatment with us if reimbursement is not necessary to cover the cost of treatment.

If you would like us to try to submit Out of Network claims electronically on your behalf, you can check the box to submit for possible Out of Network reimbursement

Payment is to be made at each session
I have read and agree to the above Fees & Insurance information.*
Insurance Disclaimer

We cannot guarantee any insurance reimbursement, but we have compiled what we have noticed from claims we have submitted on our clients behalf. We do know some insurance companies that will not reimburse, and those who may reimburse based on past experience.

Excluded Insurance Companies

These insurance plans will not reimburse for out of network services from Larch

*Anthem Blue Cross Blue Shield

*Apple Care Plans

*Medicaid Plans

*Medicare Plans

*Molina Healthcare

*Solidarity Healthshare

*Tricare
Consent to Insurance Disclaimer
I have read the above Insurance Disclaimer and the full insurance policy here
Select your Insurance Provider*
Blue Cross Blue Shield Prefix
Blue Cross Blue Shield is either processed as Regence or Premera. In order to more quickly identify if it will reimburse, please provide us with the 3 digit numerical prefix
Superbill Policy

You have selected a numerical prefix that we cannot electronically submit. When this happens, the subscriber (you) may submit with a paper form called a “Superbill”. This is a special document that is like a statement, but includes our practice information, counselor information, appointment dates, as well as the diagnosis you were seen for. All of this information is needed by insurance companies to provide out of network reimburse.

If you are using this approach, we produce the Superbill around the 10th of the month for the previous month. For example, on Dec 10th, we send you a Superbill for all of November appointments. Once you receive this document, you can mail it to your insurance company based on their process for subscribers submitting for possible out of network reimbursement. You will need to reach out to them directly to get information on where to send the documents.
After Reviewing the Superbill Policy, would you like us to produce Superbills for you to submit to your insurance provider?*

Yes Please

No Thank You
Looks like you may have an insurance plan we can submit for possible out of network reimbursement. Please complete this secure online form for us to submit electronic claims on your behalf for possible out of network reimbursement.
View the form here.
Looks like you may have an insurance plan we can submit for possible out of network reimbursement. Please complete this secure online form to update your insurance information.
View the form here.
It looks like you have selected not to have us submit on your behalf, or you have an insurance plan that will not reimburse, and we are unable to submit on your behalf
To be put on the superbill list, please email admin@larchcounseling.com to be put on the list.

Release to Bill Insurance for Intakes

Fees & Insurance Policy – Please Read and Accept our Terms

Insurance

**Out of Network Reimbursement

Insurance Disclaimer

Excluded Insurance Companies

Superbill Policy