FAA Insurance & Payment Portal

Insurance

FAA Details

Payment

Confirmation

📋 Insurance Information

Insurance Provider *

Member ID *

Group Number *

Policy Holder First Name *

Policy Holder Last Name *

Date of Birth *

✈️ FAA Certification Details

Medical Certificate Class *

1st Class Airline Transport

2nd Class Commercial

3rd Class Private / Recreational

Service Type *

Select the primary service required for your FAA medical needs.

Avaation Medical Examiner (AME) Name

Optional: If your AME requires direct communication.

Consent to Release *

I authorize In Therapy to release necessary medical information to the FAA or my designated AME as required for certification purposes. *

💳 Payment Details

✅ Insurance verified. Co-pay calculated based on your plan.

Service: Mental Health Evaluation $150.00

Insurance Coverage (80%) -$120.00

FAA Documentation Fee $25.00

Total Co-pay Due $55.00

Card Number *

Expiry *

CVC *

Billing Name *

✅

Payment Successful

Your insurance has been verified and payment processed. Your FAA therapy session is confirmed.

Ref: IT-FAA-2025-8842

Session Date: May 15, 2025 @ 10:00 AM

Status: Awaiting Therapist Assignment

A confirmation email has been sent to your registered email address.

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Need help with insurance?
billing@intherapy.com or (555) 123-4567