Current Portland DBT Institute clients or guardians can use this form if there is a change to insurance information, such as adding a secondary or tertiary policy, a switch in insurance carriers or plans, or a change in any other details that may impact our ability to bill the insurance. Remember to send us a copy of the front and back of the new insurance ID card as soon as your receive it. You can upload scans, pictures, or electronic cards to our secure file portal. You may also fax to (503) 231-8153 or mail the hard copies to our office at 5200 S Macadam Ave, Suite 580, Portland, OR 97239.
INSTRUCTIONS FOR COMPLETING THE ELECTRONIC FORM:
Please review and fill in all appropriate fields on the secure form below. After you finish and “sign” to submit, you will have the option to immediately download a copy for your records. You will also be asked to enter an email address where you would like a confirmation email to be sent, which will include a link to access and re-download the completed form (up to 30 days). Make sure to only enter an email address if you are okay with the account users potentially accessing your completed PDBTI form!
If you do NOT have an email address, or if you prefer NOT to include one for privacy reasons, please enter the following placeholder email address: firstname.lastname@example.org
If you use the placeholder email, a copy of the completed form will only be sent to PDBTI support staff for processing. You will still have the chance to download a copy of the form if you like on the submission confirmation page.
If you prefer to print and fill out a form by hand instead, please visit our Client Forms page for printable version.
If you run into any issues or need technical support, please contact our Portland front desk at (503) 231-7854 extension 0, or our Salem front desk at (503) 231-7854 extension 8, or your PDBTI therapist.