Eligibility & Benefits Verification

Rose Wellness Center Marriage Family Corp

5266 Hollister Avenue, Suite 205,

Santa Barbara CA 93111

Please fill out this form if you are an existing Rose Wellness Client and your insurance has changed, or you have added an additional plan. If you are a returning client, please fill out the form again so we can double check that everything is the same.

Client's Full Legal Name *

First, Last

Client's date of birth (DOB) *

Client's Phone Number *

Or primary contact phone # if filling out for a minor

Client's Current Address *

Client's Email *

Or primary contact email if filling out for a minor

Reason for VOB request? *

New Client
Potential new client (not set up in SP)
Returning Client
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Insurance Information

Primary Insurance (Skip if N/A or not using insurance)

If filling out for a minor- please put their insurance coverage here

Verification of benefits is a courtesy and not a guarantee of coverage. If your insurance does not cover services, you will be responsible for the amount owed each session. It is important for you to be proactive in knowing your insurance benefits. We encourage you to call your insurance representative using the member service number on the back of your card to verify this information for yourself. The insurance payor has final say on claims submitted on your behalf including any copay, coinsurance, or deductible amounts that may be owed.

Do you have Insurance? *

Yes, I am covered under ONE insurance plan
Yes, I am covered under TWO insurance plans
No, I would like to opt out of using insurance- OR your practice is out of network with my insurance
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If filling out for a minor put their insurance coverage here

Are you requesting to use EAP benefits at this time? *

Yes
No
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What is your EAP carrier?

Cigna EAP

Healthnet EAP

Optum EAP

What is your EAP authorization code/ Referral #?

Who is your Primary Insurance Carrier? *

Aetna
Anthem/ Blue Cross
Cigna /Elevance
Anthem UCSHIP (for students)
Cencal
Healthnet Commercial (through employer)
Healthnet Medi-cal (cal viva, CA health and Wellness)
United/ Optum
Other
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Who is your primary insurance under (if you selected other)

Client's relationship to primary subscriber on this plan (primary insurance) *

Client themselves
Primary Subscriber is client's spouse
Primary Subscriber is Client's parent/ guardian
Other
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Primary Subscriber (First and Last Name) Primary Plan *

Primary Subscriber's Date of Birth (primary insurance) *

Primary Insurance Member ID *

Upload Front of Primary Insurance Card *

Click upload button first, do not drag and drop

Upload Back of Primary Insurance Card *

Click upload button first, do not drag and drop

Upload Driver's License of Client

Recommended

Secondary Insurance Info (Skip if you only have one insurance)

Who is your Secondary Insurance Carrier? *

Aetna
Anthem
Anthem UCSHIP (for students)
Blue Shield of CA
Cencal
Cigna/ Evernorth
Healthnet/ MHN Commercial
Healthnet Medi-cal
United/ Optum
Other
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Insurance Carrier if you selected other (Secondary)

Client's relationship to primary subscriber (secondary plan) *

Client themselves
Client's spouse
Client's Parent/ Guardian
Other
No elements found. Consider changing the search query.
List is empty.

Secondary Insurance Member ID *

Primary Subscriber's First and Last Name (Secondary plan) *

Primary Subscriber's DOB (Secondary Plan) *

Upload Front of Secondary Insurance Card *

Upload if you have secondary insurance

Upload Back of Secondary Insurance Card *

Upload if you have secondary insurance

CAPS Anthem UCSHIP Student Referral

If you don't have a CAPS referral yet, please continue to submit form and reach out to - [email protected] to request one. Once received you can email it to [email protected]. The sooner we have this the more quickly we can get you services!

Please upload your EAP authorization letter (if you have one)