Sign View Append

Close Save & Send Download

Delete Message

Are you sure you want to delete this message?

Delete

Alma/Headway Agreement

Message From:

Eberhart Therapy, LLC

Please fill this out if you have Aetna, Cigna, Blue Cross Blue Shield, or Oscar (Optum). You will be receiving an email from either Alma or Headway. Please do fill out all forms requested on those sites in order for your insurance/billing to be set up for your first appointment.

Send a Message Along With Your Completed Form

Type text here that you want to send along with your form for the recipient to see.

Apply Electronic Signature

Type your name as you would like it to appear in your digital signature.
Name:
I agree to the Electronic Record and Signature Disclosure.

Security Check

The code you entered is not valid. Please try again.

Please type the numeric code shown above:
Code:

Please enter an email address where the form recipient may reach you.
Email:

By clicking Continue you agree to our Terms of Service and Privacy Policy.

Email Verification

Please enter your email address.

Email:

By clicking Continue you agree to our Terms of Service and Privacy Policy.

Email Verification

Please enter the verification code sent to your email:

Code:

Confirm Email

Please confirm your email address:

By clicking Yes, Continue you agree to our Terms of Service and Privacy Policy.

Signing Complete

All signatures complete. Would you like to send the document now?