Contact Us

Name: Collaborative
Price range: $$

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Contact Information

Name *

Email *

Phone *

Sex(Legal) *

At this time insurance companies only have two options. Please input what matches your current legal documents.

Preferred Location *

At this time, we are only able to provide services to New York, New Jersey, and Connecticut residents.

Date of Birth *

Provider /Service Selection

Which services are you interested in? *

If you are interested in more than one service, you may click on multiple selections.

Please select a provider *

If you do not have a specific provider in mind, please choose "Any Provider"

Billing & Insurance Information

Please tells us how you prefer to pay *

Insurance (In-Network)
Self-Pay
Out of Network

Please note: In-Network will be determined on your specific plan and you will be responsible to abide by that plans rules. We do not accept all plans or providers as primary payment.

Insurance ID *

Also known as "Member ID", If no ID, please insert NA

Upload a Photo of Your Insurance

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload a picture of the front and back of your insurance card.

Group ID

If known

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please let us know a valid address. Insurance benefits checking requirements, require us to validate this information in order to check your benefits.

Anything else you would like us to know? (optional)

Please let us know any additional details that would help us provide the best options for you.

Consent for Contact *

I agree to be contacted using the above information about medical services. I also give consent to Collaborative to use this information to check my insurance benefits, and provide information regarding services based off of that information.