Insurance, Billing & Authorization Setup — Update / setup form (auth-only) for Health Care / Therapy. Standalone version — a hosted mini landing page (an embeddable twin is also available).

How you’d like to pay and what we need to verify your benefits — names and references only, never insurance-ID or account numbers.

What it collects (by section):

• How you’ll pay — Insurance Use Intent [dropdown: Use insurance (in-network) / Out-of-network with superbill / Self-pay / EAP voucher / Sliding scale inquiry]; Payment Method Preference (health) [dropdown: Credit/Debit card / ACH / HSA/FSA card / Cash / Check].
• Your plan — Insurance Payer Name (health) [short text]; Insurance Verification Status [dropdown: Not started / In progress / Verified / Unable to verify]; Co-Pay / Co-Insurance Band [dropdown: $0 / $1-$20 / $21-$40 / $41-$70 / $71+]; Sliding Scale Interest [choice: Yes / No / Maybe]; EAP Program Name (if any) [short text]. Plan name and benefit status — never enter member or ID numbers here.
• Authorizations & documents — Referral Authorization Required [dropdown: No / Yes / Unsure]; Referral/Authorization Reference (link) [short text]; Superbill Delivery Preference [dropdown: Client portal / Email / Printed / Not applicable]; Insurance Documents Location (ref) [short text].

Form type: Update / setup (up), auth-only. Niche: Health Care / Therapy. Deployment: standalone.

Best for / surface when: Health Care / Therapy client workflow — insurance, billing & authorization setup.