INSURANCE VERIFICATION FORM
Confidential – For Internal Use Only
Section 1: Client Information
Full Name
*
Phone Number
*
Please enter a 10-digit phone number.
Date of Birth
*
Email (if available)
Client ID (Internal Use)
*
Section 2: Primary Insurance Information
Primary Insurance Company
*
Policy/Member ID#
*
Group Number
*
Plan Type (PPO, HMO, Medicaid, etc.)
*
Effective Date
*
Policy Holder Name (if different)
Relationship to Client
*
Phone # on Insurance Card (Provider Services)
*
Upload/Attach Copy of Insurance Card:
Front
Back
Upload Front Side:
Upload Back Side:
Section 3: Secondary Insurance (if applicable)
Insurance Company
Policy/Member ID#
Group Number
Plan Type (PPO, HMO, Medicaid, etc.)
Effective Date
Policy Holder Name (if different)
Relationship to Client
Phone # on Insurance Card (Provider Services)
Upload/Attach Copy of Insurance Card:
Front
Back
Upload Front Side:
Upload Back Side:
Section 4: Verification Details (To be completed by staff)
Date Verified (MM-DD-YYYY)
Verified By (Staff Name)
Section 5: Covered Services
Service Type
Covered
(Yes/No)
Prior Authorization Needed
(Yes or No)
Notes
Initial Assessment/Intake
--Select--
Yes
No
--Select--
Yes
No
Individual Therapy
--Select--
Yes
No
--Select--
Yes
No
Group Therapy
--Select--
Yes
No
--Select--
Yes
No
Intensive Outpatient Program (IOP)
--Select--
Yes
No
--Select--
Yes
No
Medication Management/Psychiatry
--Select--
Yes
No
--Select--
Yes
No
Case Management
--Select--
Yes
No
--Select--
Yes
No
Peer Support Services
--Select--
Yes
No
--Select--
Yes
No
Section 6: Authorization Details
Pre-Authorization Required:
*
-- Select --
Yes
No
Authorization Number
*
Valid From (MM-DD-YYYY)
*
Valid Through (MM-DD-YYYY)
*
# of Sessions Approved
*
Copay (per visit) $
*
Deductible Remaining $
*
Submit
