Insurance Verification Worksheet printable pdf download

OLIVE BRANCH PSYCHOTHERAPY

Dr. Stephen R. Parrish DMFT, LCPC

1601 2nd Ave. North - Suite 514 (Columbus Center) Great Falls, Montana 59401: 406-217-2338

INSURANCE VERIFICATION WORKSHEET

Client Name: Parent Name: (if child is client) ______________________________________________________

Insurance Information: Please phone your Insurance Company and ﬁll out this form the best you can.

This is very helpful information if you are unfamiliar with your coverage.

Name of Insurance: _____________________________________________________ Phone: ______________

Claims Address: _____________________________________________________________________________

______________________________________________

__________________

Insured’s Name:

ID #:

Plan/Group #: _______________________________________________________________________________

When you call be sure to write down the name of the person that you talk to for later reference.

HMO Contact Person: _________________________________Date: _____________ Time of call: ___________

Say, “I’m calling to clarify my beneﬁts and coverage for out-patient mental health.” (They will ask for your

member ID #) Ask enough questions to complete all of the information. Incomplete information will require

another phone call. “Is my therapist Dr. Stephen R. Parrish DMFT. LCPC on the Participating Provider List?”

(Name your therapist; you may ﬁnd that information on your insurance’s website, but do remember that the website might not

be up to date).

If your therapist of choice is NOT on their panel, then ask these questions:

“Does my policy allow me to choose my own therapist?”

“Can I go outside of panel or the list?” (If so, “Is my coverage different, and what difference?”)

Then ask: “What is my:

Copay: ______________% or $_____________ /session. Whichever is less.

Effective Date of Policy: ______________________________ Deductible?

Yes

Amount of Deductible $____________ / family or individual?

Deductible Per Calendar Year?

Yes

Month Deductible Begins ____________________________

Has any Deductible been met for this year?

Yes

If yes, how much? __________________________

Is Pre-authorization needed?

Yes

Any beneﬁts used to date?

Yes

Number of visits allowed per calendar year ________

# Visits allowed per 24 Consecutive months ________

Beginning: ________________

Insurance Verification Worksheet