Amy DeGirolamo
Grow Verified
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Virtual
December 2023
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Friday Dec 8th
2:00 PM - 3:00 PM UTC
2
Client information
Legal first name
Legal last name
Add a chosen name and pronouns (optional)
Email
Mobile phone number
Date of birth
Sex listed on insurance
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3
Insurance options
Provider does not accept insurance
Insurance
Cash, Out-of-pocket
4
Billing information
Why do we need this?
Credit, Debit, or HSA Card
PCI Encryption
5
Residential address
Why do we need this?
Residential address
This should be in the state from which the client will receive care
Add Apartment # or Suite (optional)
City
State
New Jersey
Zip code
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practice policies
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60 min
Virtual
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