The Mind Card™ Portal Member Status Check Member # Verify (last-4 phone OR last initial) Check Status Clinic Claim Submit Clinic access code (Clinic ID) Member # Verify (last-4 phone OR last initial) Look Up Member Date of Service Session Rate (USD) Patient Out-of-Pocket / Copay (USD) Amount Requested from The Mind Card (USD) Notes (optional) I certify that the reported patient out-of-pocket responsibility accurately reflects the patient's financial responsibility for this service based on the clinic's billing records and that the amount requested from The Mind Card does not exceed the patient's actual out-of-pocket responsibility. I certify that services were rendered on the date listed, documentation is maintained in the patient record, and The Mind Card may request supporting documentation for audit or verification purposes. Submit Claim By submitting, the clinic attests services were provided and the client authorized the claim.
