BCBS Insurance - Santo Therapy

We are only participating providers with BCBS.

JH Family Solutions are participating providers with BlueCross BlueShield ONLY. Should this be your carrier, please complete the following form and we will check your benefits, track accumulations and file directly for you. Most policies do cover some mental health counseling.

Allow us to help you better understand your policy and get benefits. Should we NOT receive your information, then payment in full is required at time of service until we receive the benefit quote through submission of the form below.

Policy Holder Information

Policy Holder Information
We will need all the information if you would like us to file to BCBS for services received, payments made.
Name of Policy Holder*
First Last
Policy Number*
WY BCBS starts with alpha-prefix followed by 12 digits Federal Policies start with R followed by digits Out of State policies may differ
Address of Policy Holder*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of birth of Policy Holder*
MM slash DD slash YYYY
Phone of Policy Holder*
Employer associated with Insurance. IF SELF EMPLOYED OR SELF POLICY, please indicate if it is under your name, or a business name*
CLIENT INFORMATION – complete ONLY if person in therapy is DIFFERENT from Policy Holder.
If seeking couple’s therapy, we file under the policy holder.
Name of CLIENT
First Last
Address of CLIENT
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of birth of CLIENT
MM slash DD slash YYYY
Phone of CLIENT
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Policy Holder Information

Policy Holder Information

CLIENT INFORMATION – complete ONLY if person in therapy is DIFFERENT from Policy Holder.