Insurance & Forms

Welcome to
Full Circle Psychology

Insurance Information & Forms to Fill out at Home

Insurance Information

I am an out-of-network provider for insurance companies not listed below. If your plan allows you to use a provider of your choice then I will bill on your behalf. Please find out if your insurance will cover my services and what your deductible and co-pays are before your first session. That will greatly ease our work together.

I am on the panels of:

Blue Shield
United Behavioral Health
Pacific Care Behavioral Health
Blue Shield MHSA as managed by Magellan
Tricare
Cigna
Ann Clark Associates (ACI)
Medicare
Victim Witness Program
Reliant Behavioral Health
Aetna
Magellan Healthcare
Managed Health Network
Anthem Blue Cross

For some insurances I will also be providing EAP services.

Paperwork

These following forms must be completed when we start our work together. You can come 15 minutes early and fill out these forms in my office if that is easier for you or you can read and print them out at home and come with them completed.

1. This form gives the basic Information I need about you:

Client Information Face Sheet

2. This information (you do not have to print) spells out all you need to know about our contract together:

Informed Consent To Psychotherapy Treatment Agreement

3. Please print, initial and sign. We will go over this material together the first time we meet.

Signature Page confirming that you have read and understood the "Informed Consent to Psychotherapy Agreement" for treatment

4. Please read the following pages (you do not have to print these) about your privacy rights and then sign the signature receipt page in 5.

California Notice of Privacy Practices

5. Please print and sign this.This page also has a release to allow me to bill your insurance company, if applicable.

Signature Page for the receipt of the "California Notice of Privacy Practices" including a release to bill your Health Insurance Company

6. Please print, initial and sign.

Courtesy Agreement

Most will not need to fill out the following forms:

Additional Forms:

Print and sign the Consent for Assessment form only if you are going to come for an initial consultation as a person not planning on using insurance. If you use this form then you don't yet have to read or sign the Consent for Treatment or Release of Information forms at this time.

Consent for Initial Assessment

A release for me to be in contact with your primary care physician or any other person if applicable.

Release of Information Form--Simple Version

This is a thorough release of Information form if more exchange is needed than brief contact with your PCP or any other person.

Release of Information Form--More Detailed