INSURANCE VERIFICATION FORM

Back to forms                                                                                                       Press "Control P" to print

This form requires a phone call to your insurance company to be accurate.  

Your insurance card does not have the needed information.  Please complete the entire form.  Failure to do this highly increases the likelihood your sessions will not be covered!  It is for your protection, as I do not have the resources to verify benefits for every client I see.

COMPLETE ALL SECTIONS BELOW WHILE TALKING TO YOUR INSURANCE COMPANY.

Insurance Company _____________________________________________________

Insurance Phone # ______________________________________________

Social Security # of Primary Insured ____________________________________

Insurance I.D. (on card if different) __________________________________________

Group # (if any):_{__________________________________________________________________}

Primary Insured Name ____________________________________________________

Employer ________________________________________________________

Patient Name _________________________________  

Patient Date of Birth __________________

SECTION 1  -  Regular Therapy Sessions

Maximum # sessions annually on your plan  _________

Amount of copay (this is due each visit)   ___________           

Deductible on your plan ____________            

Amt of deductible already met ____________     

For regular therapy sessions, is authorization required?            

___ no  ___ yes

Authorization number (if obtained)

_____________________________________________

# of sessions authorized ____________      

Address for behavioral health claims 

______________________________________________

(Address can only be obtained by calling the insurance company.  Address on your card is for medical claims, not counseling). 

If your plan is an out-of-state Blue Cross/Blue Shield policy, does it accept a Licensed Marriage & Family Therapist?                                              

____ n/a      ____ yes  ____ no

SECTION 2  -  Employee Assistance Programs (EAP)        

Is this an EAP visit?      ____ no    ____ yes        

If so, authorization number ______________________

Name, phone # of EAP (if different) __________________________________

# of EAP sessions authorized ___________        

Address for EAP claims ___________________________________________

Your signature below confirms you understand the importance of obtaining accurate, thorough information.

                                    Signature                                                              

                                       Date