Insurance Verification Form
ADVERTISEMENT
1Insurance Verification Form
Youth & Family Counseling
1113 S. Milwaukee Ave, #104
Libertyville, IL 60048
If you are using insurance, please complete the following questions
847-367-5991
and give your insurance cards to staff to be copied.
Tax I.D. 36-6148486 NPI 1487770798
Insured’s Name________________________________________________________________________
Insurance ID ________________________________
SS#________-_______-___________
Insured’s Relationship to Client: Self Spouse Child Guardian Other _________ _____
Insured’s DOB____/____/______ Insured’s Sex M F
_______________________________________________________________________________________________
Street
Apt #
City
State
Zip
(___)_____________________(___)______________________________(___)_______________________________
Home
Work
Ext
Cell
Primary Insurance Company’s Name ________________________________________________________________
Insurance Company’s Phone (___) ______________ Behavioral Health Phone (___) ________________________
Policy # ____________________________________ Employer _________________________________________
Group # ____________________________________ Plan Name ________________________________________
Secondary/Supplemental Insurance Company’s Name ____________________________________________
Insurance Company’s Phone (___) ______________ Behavioral Health Phone (___) ________________________
Policy # ____________________________________ Employer _________________________________________
Group # ____________________________________ Plan Name ________________________________________
Is your behavioral health care managed?
Yes No If yes, MC Co. Name___________________________
Is precertification/preauthorization required?
Yes No If yes, by whom? Client PCP Therapist/YFC
Phone number to precertify treatment: (______)__________________.
Have you received authorization for treatment? Yes No If yes, please provide the following information if
known: Authorization #____________________ # of Sessions Approved_________ Start Date ____/_____/______
Other Information you want us to know about your insurance coverage
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
For Office Use Only
Yes
No
Effective Date of Insurance:____/______/________
Family therapy (90846/90847) covered?
Type of Insurance:
PPO
HMO
POS
______________
Deductible $___________ How much met YTD $___________
Yes
No
Out of Network Coverage/Benefits?
Copayment/Coinsurance________________________________
_____________________________________________________
Notes________________________________________________
Yes
No
LSW, LPC or Interns under supervision covered?
_____________________________________________________
Publisher 2010 Revised 3/2/2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal