Insurance Verification Form

Member's Full Name

Sex

Member's Current Home Address

Member Phone #

Date of Birth

Social Security Number

Optional

Mental Health Diagnosis Code(s)

Anticipated CPT Code(s) for Procedure

Upload the GOVERNMENT ID here

Are you a dependent on someone's insurance

Yes

Example of dependent: Are you on a parent or spouse insurance?

Type of Insurance

Member's First Name

Member's Last Name

Member Address associated with insurance

Name of Insurance

Insurance Phone #

Insurance Plan Type (HMO, PPO, Medicare, Medicaid)

Member/Policy No.:

Group No.:

Subscriber insurance Information

Subscriber Full Name:

Subscriber Date of Birth

Subscriber Relationship to Member

Subscriber's Phone #:

Subscriber's Address associated with insurance

Upload the FRONT OF INSURANCE CARD here

Upload the BACK OF INSURANCE CARD here

Coverage Start Date:

Do you have patient responsibility?

Copayment:

Specialist cost per visit

Current Deductible

Annual Deductible

Coinsurance: ____%

Out-of-Pocket Limit: $______

Benefits

Referral Necessary?

Prior Authorization Required

Out-of-Network Coverage?

Out-of-Network Financial Responsibility: