Insurance Verification
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 __________________________
Outpatient Coverage
Diagnosis
Code ____________________
Procedure Code _______________
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?
Preapprovals, Treatment
Authorizations?
Procedure Codes?
Billing requirements?
Name of person verifying benefits
_______________ Phone_______________
Date______________
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