Insurance Verification Form

Insurance   V erification   F orm  

Today’s   D ate:   _ ________________________________  

Therapist:   _ _____________________________________________________  

Client   N ame:   _ __________________________________   D OB____________________________  

Address:_______________________________________Phone:___________________________  

Insurance   C ompany:________________________________   P hone:___________________________  

Policy   H older:   _ ____________________________________________DOB_______________________  

Policy   H older   A ddress   a nd   p hone:________________________________________________________  

Employer:____________________________________   I D   # :___________________________________  

Group   # ______________________________________  

Reason   f or   v isit:_______________________________________________________________  

BENEFITS:  

Effective   d ate   _ ____________________  

Copay   a mount   _ _______________________  

Deductible?     Y es     N o     I f   y es,   w hat   i s   t he   d eductible?   _ ___________________________  

Has   t he   d eductible   b een   m et   t his   y ear?     Y es     N o  

What   p ercentage   o f   t he   c harges   d oes   t he   p lan   p ay?   _ ______________  

Is   t here   a   l imit   t o   t he   n umber   o f   v isits   p er   y ear?     Y es     N o     I f   y es,   w hat   i s   t he   l imit?   _ _______________  

Is   t here   a   p re-­‐existing   c lause   t o   t his   p lan?     Y es     N o         I s   p re-­‐authorization   r equired?     Y es     N o  

Referral/Authorization   # ___________________________     V isits   _ _______________________  

Effective   D ates   _ __________________________________  

Spoke   t o:   _ ______________________________________________________________    

I   a uthorize   J ulie   F ord,   M FT   t o   r elease   t o   t he   a bove   i nsurance   c ompany(s)   a ny   i nformation   w hich   s aid   c ompany   m ay  

request   c oncerning   p ayment,   e valuation,   o r   t reatment   o f   t he   a bove   n amed   c lient.   I   a uthorize   m y   i nsurance  

company   t o   m ake   p ayment   d irectly   t o   J ulie   F ord,   M FT   f or   i nsurance   b enefits   o therwise   p ayable   t o   m e.   I   a gree   t hat  

a   p hotocopy   o f   t his   a uthorization   s hall   b e   c onsidered   a uthentic.   I   u nderstand   t hat   I   a m   f inancially   r esponsible   f or  

those   c harges   n ot   p aid   b y   m y   i nsurance   c ompany,   i ncluding   c o-­‐pays,   d eductibles,   a nd   a ny   d ifferences   i n   a mount  

charged   a nd   a mount   n ot   c overed   b y   i nsurance.    

Signature______________________________________________________Date__________________________