Verification of Eligibility/Benefits
If you are interested in using Insurance Benefits or Employee Assistant Benefits to pay for counseling services, please complete the following information. You may upload a copy of your insurance card to attach to this form.
By completing and submitting this information you are giving permission for the clinical and/or administrative staff of Kelly Counseling & Associates to view your benefits. Verification of benefits is not guarantee of payment.
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  • Requested Counselor