"Mental Health/Behavioral Health Insurance Benefits Verification Form - the Atlanta Counceling Group Llc"

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Mental Health/Behavioral Health
Insurance Benefits
Verification Form
Complete the following information then call the customer service number on your insurance card and ask
the questions below.
Client’s Name: ____________________________________________________________________________
Client’s Date of Birth: ____-____-____
Client’s Soc. Sec. #: _____-____-______
Policy Holder’s Name (if different from client): __________________________________________________
Policy Holder’s Date of Birth: ___-___-___ Policy Holder’s Soc. Sec. #: ____-___-______
Primary Insurance /Behavioral Health Insurance Plan: ____________________________________________
Note: This may be different from your medical health insurance plan
Member ID #: _____________________________ Group #: _____________________________
Questions for Your Insurance Provider
1) “Do I have mental/behavioral health coverage?” □ YES □ NO
(If YES, continue. If NO, there is no need to proceed, other payment arrangements must be made. Please contact
the therapist with whom you want to work to discuss payment options.)
2) “Is my preferred therapist ____________________________________in network?” □ YES □ NO
(If YES, go to In-Network Coverage, If NO go to question 3)
3) “Do I have Out-of-Network benefits?” □ YES □ NO
(If YES, go to Out-of-Network benefits. If NO, there is no need to proceed, other payment arrangements must be
made. Please contact the therapist with whom you want to work to discuss payments options.)
In-Network Coverage
4) “What is my co-pay amount?”
$__________
5) “Do I have a deductible?” □ YES □ NO
6) If YES, “What is my deductible?”
$__________
(Now proceed to Services Covered)
Out-of-Network Benefits
7) “How much will I be reimbursed if I see an Out-of-Network therapist?” $__________
8) “Do I have an Out-of-Network deductible?” □ YES □ NO
If YES, “What is my out-of-network deductible?”
$__________
Services Covered
9) “Please verify that the following services are covered under my policy?”
CPT Code 90834 □ YES □ NO
CPT Code 90837 □ YES □ NO
CPT Code 90853 □ YES □ NO
Services Authorized
10) “Do I need an authorization to receive any of these services?” □ YES □ NO
If YES, “What is my authorization number?” __________________________________ and
11) “How many sessions are authorized?” _______________.
Revised: JAN2014
Mental Health/Behavioral Health
Insurance Benefits
Verification Form
Complete the following information then call the customer service number on your insurance card and ask
the questions below.
Client’s Name: ____________________________________________________________________________
Client’s Date of Birth: ____-____-____
Client’s Soc. Sec. #: _____-____-______
Policy Holder’s Name (if different from client): __________________________________________________
Policy Holder’s Date of Birth: ___-___-___ Policy Holder’s Soc. Sec. #: ____-___-______
Primary Insurance /Behavioral Health Insurance Plan: ____________________________________________
Note: This may be different from your medical health insurance plan
Member ID #: _____________________________ Group #: _____________________________
Questions for Your Insurance Provider
1) “Do I have mental/behavioral health coverage?” □ YES □ NO
(If YES, continue. If NO, there is no need to proceed, other payment arrangements must be made. Please contact
the therapist with whom you want to work to discuss payment options.)
2) “Is my preferred therapist ____________________________________in network?” □ YES □ NO
(If YES, go to In-Network Coverage, If NO go to question 3)
3) “Do I have Out-of-Network benefits?” □ YES □ NO
(If YES, go to Out-of-Network benefits. If NO, there is no need to proceed, other payment arrangements must be
made. Please contact the therapist with whom you want to work to discuss payments options.)
In-Network Coverage
4) “What is my co-pay amount?”
$__________
5) “Do I have a deductible?” □ YES □ NO
6) If YES, “What is my deductible?”
$__________
(Now proceed to Services Covered)
Out-of-Network Benefits
7) “How much will I be reimbursed if I see an Out-of-Network therapist?” $__________
8) “Do I have an Out-of-Network deductible?” □ YES □ NO
If YES, “What is my out-of-network deductible?”
$__________
Services Covered
9) “Please verify that the following services are covered under my policy?”
CPT Code 90834 □ YES □ NO
CPT Code 90837 □ YES □ NO
CPT Code 90853 □ YES □ NO
Services Authorized
10) “Do I need an authorization to receive any of these services?” □ YES □ NO
If YES, “What is my authorization number?” __________________________________ and
11) “How many sessions are authorized?” _______________.
Revised: JAN2014