Middletown Counseling Services

401 North Broad Street
Middletown, DE 19709
302-376-0621
Fax : 302-376-6219

Authorization Form

Tax ID: 01-0814087

Client’s Name : ____________________________

Current Client? :  _________   If so, Therapist name: ____________________________

Client’s Birth Date : ____________________________________

Client’s SS# : ________________________________________________

Member ID# : ________________________________________________

1. Is pre-certification required ? : _____________________________
2. Number of yearly visits : _________________________________
3. Name of person I spoke with : _____________________________
4. Deductible : ______________ Paid so far this year : ____________
5. Effective date of policy : __________________________________
6. Any restrictions as to whether the treating person be an LCSW, LPCMH, of Ph.D? _______________________________________________________
7. Co-Pay : _________________

Claims Address : _______________________________________________________________

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_____________________________________________________________________________

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Authorization # : _________________________________________________________