Insurance Verification For Physical Therapy Benefits printable pdf download

Insurance Verification For Physical Therapy Benefits

INSURANCE VERIFICATION FOR PHYSICAL THERAPY BENEFITS

Patient Name__________________________ Subscriber Name____________________

Subscriber ID#_________________________ Subscriber Date of Birth______________

Date of Call__________ Insurance Company Name______________________________

Insurance Company Phone #___________________ Contact Person_________________

(located on back of card)

Effective Coverage Dates____________________ Physical Therapy Benefits? Yes No

Are there limits to these Physical Therapy benefits? Yes No

Number of Visits_______________ Dollar Amount______________

Have any benefits been used this year? Yes No

Number of Visits_______________ Dollar Amount______________

Does this plan have a deductible? Yes No

How much is this deductible?____________________

How much of it has been met?____________________

What percentage of the allowable charge is paid by insurance?________________

What percentage of allowable charge is patient responsibility?________________

Is there a co-pay? Yes No

How much?_______________

ARE EITHER OF THE FOLLOWING REQUIRED FOR PHYSICAL THERAPY TO

BE COVERED?

PRIOR AUTHORIZATION/REFERRAL

The process for this varies depending on the insurance company. Typically, the doctor

referring the patient to physical therapy submits a request for prior authorization to the

insurance company. The insurance company then authorizes how much physical therapy

they will cover.

________________________________________________________________________

REFERRAL/WRITTEN ORDER/PRESCRIPTION

Referring doctor gives this to patient to bring to physical therapy.

________________________________________________________________________

Insurance Verification For Physical Therapy Benefits