Insurance Verification-Inpatient 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?____________
_______________________________________________________
Inpatient Coverage
Admitting
Diagnosis Code__________________
Procedure Code___________
Physician's coverage
for daily visit___________________________________
Psychologist's coverage
for daily visit_________________________________
Coverage for
physician and psychologist same-day visit__________________
Family Therapy:
Yes____ No____ Amount________ Maximum # of visits____
Supervision of treatment
team: Yes____ No____ Maximum # of visits______
Inpatient Psych
Testing: Yes____ No____ Amount_______ Limitations______
______________________________________________________________
Any Exclusions:
yes_____ No_____ If yes, what?______________________
______________________________________________________________
Will insurance
cover hospitalization in free standing psych hospital?________
Amount of deductible $______________ Is deductible
met? _____________
Maximums: Yearly $___________
Lifetime $_______________
Remaining days
of coverage lift __________________________
Any special procedures?
Network or out-of-network
coverage?
Preapprovals, Treatment Authorizations?
Procedure Codes?
Name of person verifying benefits
_______________ Phone_______________
Date______________
.
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