Insurance Verification-Outpatient Treatment

Patient's Name________________________ Physician___________________

Insured's Name_____________________ Insured's I.D.No._______________

Employer_________________ Policy Identification______________________

Name of Insurance________________________________________________

Billing Address___________________________________________________

Effective date of coverage or start of contract year__________________

Subject to preexisting?____ If yes, what an how long?_________________

_______________________________________________________________

Amount of deductible $______________ Is deductible met? ______________

Amount paid per visit_______% of $______ Amount of co-pay_____________

Actual amount paid by insurance Company per session $_____________

If fee is $150.00 per visit, what is actual amount paid? $_____________

Maximum allowable visits per year____ Maximum paid per year $__________

Psychological Testing: Yes_____ No_____ Amount $____________________

Is testing paid same as psychotherapy visit? Yes_____ No____

Any Exclusions: Yes_____ No_____ If yes, what?_______________________

Any special procedures?

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Name of person verifying benefits _______________ Phone_______________

Date______________

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