Mental Health/behavioral Health Insurance Benefits Verification Form printable pdf download

Mental Health/Behavioral Health

Insurance Benefits

Verification Form

Complete the following information then call the customer service number on your insurance card and ask

the questions below.

Client’s Name: ____________________________________________________________________________

Client’s Date of Birth: ____-____-____

Client’s Soc. Sec. #: _____-____-______

Policy Holder’s Name (if different from client): __________________________________________________

Policy Holder’s Date of Birth: ___-___-___ Policy Holder’s Soc. Sec. #: ____-___-______

Primary Insurance /Behavioral Health Insurance Plan: ____________________________________________

Note: This may be different from your medical health insurance plan

Member ID #: _____________________________ Group #: _____________________________

Questions for Your Insurance Provider

1) “Do I have mental/behavioral health coverage?” □ YES □ NO

(If YES, continue. If NO, there is no need to proceed, other payment arrangements must be made. Please contact

the therapist with whom you want to work to discuss payment options.)

2) “Is my preferred therapist ____________________________________in network?” □ YES □ NO

(If YES, go to In-Network Coverage, If NO go to question 3)

3) “Do I have Out-of-Network benefits?” □ YES □ NO

(If YES, go to Out-of-Network benefits. If NO, there is no need to proceed, other payment arrangements must be

made. Please contact the therapist with whom you want to work to discuss payments options.)

In-Network Coverage

4) “What is my co-pay amount?”

$__________

5) “Do I have a deductible?” □ YES □ NO

6) If YES, “What is my deductible?”

$__________

(Now proceed to Services Covered)

Out-of-Network Benefits

7) “How much will I be reimbursed if I see an Out-of-Network therapist?” $__________

8) “Do I have an Out-of-Network deductible?” □ YES □ NO

If YES, “What is my out-of-network deductible?”

$__________

Services Covered

9) “Please verify that the following services are covered under my policy?”

CPT Code 90834 □ YES □ NO

CPT Code 90837 □ YES □ NO

CPT Code 90853 □ YES □ NO

Services Authorized

10) “Do I need an authorization to receive any of these services?” □ YES □ NO

If YES, “What is my authorization number?” __________________________________ and

11) “How many sessions are authorized?” _______________.

Revised: JAN2014

Mental Health/behavioral Health Insurance Benefits Verification Form