Emotional Wellbeing Solutions Visit Authorization Request

Please answer all questions below
* indicates required fields

Requester information

Effective date of authorization

mm/dd/yyyy

First name

Last name

Policy holder's Member ID (optional)

Policy holder's employer

Policy holder's address 1

Policy holder's address 2 (optional)

City

Zip

Requester's birthdate

mm/dd/yyyy

Requester's email

emailuser@example.com

Requester's phone number

###-###-####

Can we leave a message at this number?

Yes

Please list your other concerns only if they are not listed above.

Required

I agree to receive my authorization via email.