Insurance Form Insurance Form Date MM slash DD slash YYYY Insurance Status*I am a new patientI am a new patient covered under a parental planI am updating or changing insurance.I elect not to process insurance at this timeName* First Last Permanent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Local Address (if student or temprorary residence)* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Date of Birth*Insurance Name*Blue Cross Blue ShieldCignaOptum Products: UBH, Allways HealthI will be paying privatelyFull Plan Name*Identification Number:*Policy Holder Name, DOB and Address*CoPay listed for BH or Specialist*Please indicate if you will be pre-paying for co-pays through the appointment confirmation email or other method.*Pre-Payment through the Appointment Scheduling linkI prefer to be invoiced for co-paysCheck mailed to 82 MArlborough St, Boston, MA 02116Venmo to Kathleen Andolina, PMHCNS-BC@KAthleenAndolinaCash (in office only)Processing of Insurance Benefits* Yes, I accept insurance assignment of benefits to this provider Yes, I authorize insurance and medical information release for the purposes of processing claims No, I do not accept insurance processing at this time Billing and Service Information I have reviewed the "Billing and Service" informationEOBs: Please check your mail or online accounts for Explanation of Benefits (EOBs) to stay informed about co-insurance, copays, or deductibles due at the time of your visit. Don't forget to check your SPAM folder in case they end up there. Updating Insurance: Please send new insurance information as soon as possible via the online Insurance form Payment Options: • Checks: Mail to 82 Marlborough St, Boston, MA 02116. • Cash: Collected during in-office appointments. • Venmo: Kathleen Andolina, PMHCNS-BC@KathleenAndolina. • Online Invoicing: Invoices can be sent to your email with links to pay by credit card, FSA/HAS cards or Paypal. • Pre-Pay Copays: Use the COPAY or scheduling link to pay copays in advance. Refill Requests: Appointments are the preferred method to request medication refills. Email/Texts: Please use email or text thoughtfully as I check them in the early mornings and after 5 PM. Important information is welcome, but please avoid excessive communication to minimize disruptions. In-Person Appointments: • DEA Requirement: In-person visits are required for new patients prescribed Schedule II medications (as of Nov 2023). • In-Office Appointments: Fridays only at 82 Marlborough St, Boston, MA. Appointment Scheduling & Pre-Payment of Copays: • Copays may be paid online through the Appointment scheduling and confirmation emails you receive. Book/Change your Appointments: (existing patients only) You can book, change and pay for your next appointment at the same time, simply select the day and time you prefer. If you pre-pay and the appointment is cancelled or re-scheduled you will carry a credit for the copay amount. Discounting Policy: To support students, seniors, veterans, and underserved individuals, I may offer discounts (50-75%) or waive copays for qualifying patients. Flexible payment plans are available for those with accumulated balances. Note: Discounting does not apply to out-of-network benefits. If you're submitting a bill for reimbursement, you must pay first and then submit the paid bill to your FSA, HSA, or insurance company. COVID Precautions: Air filtration, chair distancing, and masks available as needed during office visits. 2025 Private Pay Rates: • Initial Session: $300 • 45-Minute Session: $225 • 20-Minute Session: $180 2025 Office Hours: • Mondays: 9 AM - 2 PM • Tuesdays: 9 AM - 5 PM • Wednesdays: Off • Thursdays: 9 AM - 12 PM, 1 PM - 4 PM, 6 PM - 8 PM • Fridays: In-Office, 10:30 AM - 4 PMPlease upload a picture of the front and back of your insurance card:*Max. file size: 888 MB.