May 22, 2025 by Karen Buckley Insurance Verification Form You are 100% responsible for all services rendered. Insurances typically only cover a portion of your bill. You may also be subject to Co-Pays and Deductible. It is your responsibility to contact your insurance plan to understand what they will cover. In any event you are responsible for all incurred services and are expected to pay your bill on time. Do you have insurance? * Yes No Please note: You are responsible to know and verify your benefits prior to any services. It is also your responsibility to notify the office of all changes in your insurance. Please have your insurance card available at your appointment as we will need a copy. Complete the below insurance Information Your First Name * Your Last Name * Date of Birth * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Employer * Are you the primary on the insurance? * yes no First name of Primary * Last name * Date of birth of primary * Employer * Insurance information Insurance company name Insurance Policy or ID number Insurance group number Insurance phone number Number of approved visits Do you have a Deductible? yes no Amount of Deductable How much of Deductible has been met? Do you have a Co-Pay? yes no Amount of Co-Pay Do you need a Referral for counseling? yes no If yes, you are responsible for obtaining that. Did you confirm that Karen M. Buckley, LICSW, ACSW, OSW-C is covered by your insurance? yes no In or out of network? yes no Benefit Information Do you have a secondary insurance * Yes No Section Secondary Insurance Information Same information as above * Yes No First Name Last Name Secondary insurance company name Date of Birth Secondary insurance Policy or ID number Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Are you the primary on the insurance? yes no First name of Primary Secondary insurance group number Last name Date of birth of primary Secondary Insurance phone number I agree to Billing and Payment terms * Yes Date If payments are not made on time all future appointments will be canceled until your balance is paid in full. * I agree Date Phone * Submit This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Captcha If you are human, leave this field blank. Karen M. Buckley, LLCOlympia, WA 98501Phone: (360) 556-0201Fax: (360) 357-6218Contact us
