New Client Insurance Verification Form printable pdf download

Soul Work Counseling

11108 Zeland Ave N, Suite 104, Champlin, MN 55316

Phone: 763-746-0842 Fax:763-746-0843

New Client Insurance Verification

Patient Information

Patient Name _______________________________________________________________________________

Age ____ Date of Birth _______________ Gender_____ Marital Status ______

Home Address________________________________________________________Apartment#

City__________________________________________________State_________________Zip

Phone: Home _________________________ Cell ____________________________ Work ____________________________

Insurance Information

► All information is required to obtain benefit information ◄

Name of PRIMARY

Insurance Co. __________________________________________ Insurance Phone (from back of card) _____________________

Group/Acct #_________________________________ Member ID#_______________________________________

Policy Holder’s: Name _________________________________ DOB_________ Relationship to Pt. ___________________

Police Holder’s Employer (If insurance is obtained thru employer)_________________________________________________

Does the patient have secondary insurance? ___ No ___Yes If Yes, please complete page 2 for secondary insurance.

I assign all benefits from insurance or other third-party coverage to Soul Work Counseling. Further, I understand that by signing this form I acknowledge

that if my insurance carrier or HMO/PPO does not cover certain services, I will pay for them in full. I authorize the release of any medical information necessary to

process any claim for services provided by Soul Work Counseling. A photocopy of this authorization may be honored.

Signature:_________________________________________Date:________________

Benefit & Eligibility Information: To Be Completed by Office

Effective Date__________________% Covered___________% Deductible $__________________ Copay $__________

Amount paid towards deductible: _________________ Group: 2:1_____ 1:1 _____ Group Copay $ ________________

Max out of Pocket $_____________________________ Max Payable by Insurance $______________________________

Soul Work Counseling Rep

Verification by:

_____ Ins Rep _______Date________ Private Pay Amount $ _________

Private Pay Group $______

□

No Authorization is required