Self-Pay Profile Request Form

Each Regional Billing Specialist will create profiles for self-pay clients, adding the appropriate CPT codes and rates. *Please note: If a sliding scale rate has been negotiated, that rate must be shared with the Regional Billing Specialist. Please send all billing and/or insurance questions to your Regional Billing Specialist:

Region A: Erik Hall (Downtown Raleigh, East Raleigh, North Raleigh, West Raleigh, Midtown)
RegionA@threeoaksbehavioralhealth.com

Region B: Lisa Moore (Knightdale, Garner, Chapel Hill, Telehealth)
RegionB@threeoaksbehavioralhealth.com

Region C: LaShawn Willingham (Pittsboro, Southern Village, Chapel Hill, South Durham, North Durham, Apex)
RegionC@threeoaksbehavioralhealth.com

Region

Three Oaks Clinician's Name

First Name

Last Name

I am requesting

A new profile to be created.

An update to an existing profile.

Requested Profile Type

Please select all that apply.

Individual

Minor

Couples

Individual in Group Therapy

Psychological Testing/Evaluation

Client's LEGAL Name

First Name

Last Name

Client's Preferred Name/Nickname

We recognize and honor that many of our clients identify by names other than their current legal name and know, express, and/or identify their gender in a non-binary way.

First Name

Last Name

Client's Date of Birth:

Client's Sex:

Currently, these are the only options available in SP. We are hopeful that this will be updated soon!

Phone

(###)

###

####

Session Location

Where will be majority of your sessions take place?

Will you be using the Three Oaks self-pay rates?

Yes

Rate Charged for Sessions

Self-Pay Profile Request Form

Thank you! We have received your request. You should hear back within 3 business days.

Three Oaks Behavioral Health & Wellness

Mailing Address

Contact Us