J. Mike Ross, Ph.D.
Licensed Psychologist, Life Coach
Closed Office due to move to Arizona
512-983-1120
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    Closed office due to move to Arizona    

       
  1. I invite you to call me (Dr. Mike Ross) directly at 512-983-1120 if you have questions or would like to schedule an appointment. You may also contact me by email at DrMikeRoss@sbcglobal.net
    OR you may use the contact form by clicking here.
  2. This step only applies if you are using insurance. After making an appointment or talking with me, you may provide your insurance information by completing the form below. My insurance professionals will use this information that you provide to verify your insurance benefits and to make arrangements to maximize the use of your insurance plan. Please do this as soon as possible so they will have enough time to get your benefits verified and obtain any pre-authorizations that may be required. You will only be able to pay a lower fee according to your insurance plan, if proper verification has been completed through my insurance service before your appointment.
  3. There are some forms that you will need to complete and review before your appointment. (1) You may arrive 15 minutes before your scheduled appointment and complete the paperwork provided on clipboards in my private waiting area (located on the shelf by the receptionist window). (2) Most clients prefer to download, print, and fill out the paperwork by clicking on the links below.  

    Click here to download forms that you need to complete, review and sign. For couples and families, each person attending the session(s) must complete all of these forms (print as many copies as needed).

    Click here to download important information including the HIPAA disclosure about confidentiality. There isn't anything on these forms that you need to complete or sign; it is for your information.
      
  4. Attend the session as scheduled. If you are unable to attend the session, please provide at least 24 hours notice (if unable to provide 24 hours notice, any notice would be appreciated).
     
    Click here for one page map and directions to my office.   
  5. Complete the form below, only if you plan to use insurance.

       

 
Insurance Verification Form

Please complete the information requested below. Incorrect or incomplete information may delay authorization process; thus, please carefully review your information before submitting it. Thank you!

First Session Date and time:
Type of counseling:
 (Check all options that apply) Individual
  Couples
  other
Name (first name, last name):
Date of Birth (mm/dd/yyyy):
Insurance Company Name:
Member ID #:
Insurance Group #::
If patient is not insurance subscriber, Subscriber name:
Subscriber's Date of Birth:
Your phone number (include area code):
Your street address, apt, etc.:
Your City, State, Zip:
Your email address::
Phone number for behavioral/mental health (Back of card):
Provider Services Number (Back of card):
Member services number (Back of card):
Gender:
 (Check your gender) Female
  Male
Marital Status:
 (Check your marital status) Single
  Married
  Other
Employment Status:
 (Check your employment status) Employed
  None
  Retired
  Full Time Student
  Part-Time Student
Employer/School Name:
If insured is someone other than the patient, complete the info below.
 (Check your relationship to insured) Spouse
  Child
  Other
Insured Employer:
Insured address same as patient?:
  Yes
  No
Insured street address, apt #, if different than patient:
Insured city, state, zip, if different than patient: