Grapevine Mind & Body, PLLC - Insurance & Forms

Insurance & Forms

We are in network with the following insurance groups:

Aetna, BlueCross/Blue Shield of Texas, Humana, Medicare, MultiPlan/PHCS and United Behavioral Health.

*Please Note:

We will need to verify your benefits to confirm your eligibility of coverage.

Forms & Office Policies:

(Click on the highlighted text to access forms.)

1. Patient Information Sheet (Please complete in its entirety and email or fax back

along with a copy of the front & backof your insurance card.)

2. HIPPA Privacy Practices (please review before signing

acknowlegement) consumer rights and consumer summary

3. Privacy Practices Acknowlegement (please bring completed form to initial visit)

4. General Consent for Treatment (please bring completed form to initial visit)

5. Cancellation Policy (please bring completed form to initial visit)

7. Office Policy for Prior Authorizations and Paperwork (for your review)

All staff at Grapevine Mind & Body, PLLC is compliant with HIPPA guidelines.