Payment | Reimbursement Options This form is confidential Name First Last Insurance Company ID Number Group Number Co-Pay Amount (Office Visit)Co-Pay Amount (Specialist)Employee Assistance Program (EAP) Authorization Number Number of Sessions Authorized Δ Pay by Check, Money Order, or Cash Only No Credit or Debit Cards Accepted Private Pay - $125 for First 1 Hour Session $100 for Each Subsequent 1 Hour Session