Request for Mental Health and Wellness Benefits

Mental Health benefits requested by: Select OneBeneficiary themselvesDoctor / PCP

Beneficiary Insurance: Select OneTraditional / Straight MedicareMedicare Advantage ( HMO / PPO )

Location for benefits to be provided: Select OneAL or IL addressTheraCounsel office: 4546 North Federal highway Ft. Lauderdale FL 33305.