MENTAL HEALTH BENEFITS WORKSHEET
I work with a number of insurance companies and employee assistance programs. Before we begin our sessions, it
is important to know what your benefits are. To assist you in the process I have provided this worksheet to be filled
out and then brought with you to your first session. Have your insurance card handy when you call the customer
service number because you will need the Client ID and group numbers in order to determine your eligibility/
benefits.
COMPLETE THE FOLLOWING PRIOR TO MAKING THE CALL TO CUSTOMER SERVICE
Client Name: ___________________________________________ DOB: ________________________
Subscriber’s Name: ______________________________________ Employer: ____________________
Client ID#: _____________________________________________ Group #: _____________________
Insurance Company: _____________________________________ Insurance Phone: _______________
COMPLETE THIS SECTION DURING THE CALL BY ASKING THESE QUESTIONS BELOW
Does my plan cover mental health services? Yes No
(If not, then speak with me about a cash payment arrangement)
Is Wendy Biondi a network provider? Yes No
If no, does my plan have out of network mental health benefits? Yes No
(If not, then speak to me about a cash arrangement)
What is my deductible? ___________________ Has my deductible been met for the year? Yes No
What date does my coverage renew on? ____________________________________________________
Yes No
Do I have a co-pay or co-insurance?
If so, Co-pay $ __________________ Co-insurance $/% ________________
How many visits do I get per year? _________________ How many visits have I used? _____________
Does my plan require a referral from my primary care provider (PCP)? Yes No
(If yes, contact your PCP and request a referral to see me)
Does my plan require a pre-authorization? Yes No
If so ask how to obtain the authorization: ___________________________________________________
Authorization #: _______________________________ Number of Visits Authorized: _____________
Start Date: ____________________________________ End Date: _____________________________
IF APPLICABLE: Does my plan cover any of the following?
Family Therapy Yes No
Marriage Counseling Yes No
Group Therapy Yes No
Be sure to bring a copy of this completed form and your insurance card with you to your first
session so that we can review it.
Biondi: Benefits Worksheet, 8/2012