Verifying Insurance Benefits
This information is provided as a courtesy so you can check your benefits.
Patient’s Name: __________________________________________________________________________
Patient’s Date of Birth: _____-____-______
Policy Holder’s Name (if different from patient):_______________________________________________
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 #: _____________________
Dependent’s ID #: (if child is the patient, there should be a number listed after his/her name): ___________________________________
Effective Date of Policy: _____-____-______ Expiration Date of Policy: _____-____-______
Questions for Your Insurance Provider:
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“Do I have mental/behavioral health coverage?” □ YES □ NO
2. “Do I have Out‐of‐Network benefits?” □ YES □ NO
Out‐of‐Network Benefits
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“How much will I be reimbursed if I see an Out‐of‐Network provider?” $__________
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“Do I have an Out‐of‐Network deductible?” □ YES □ NO
If YES, “What is my Out‐of‐Network deductible?” $__________
Services Covered: In-Network BCBS-IL PPO, Blue Choice PPO, and Cigna PPO
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“Can you please verify that the following services are covered under my policy?”
•Individual Therapy □ YES □ NO •Medication and Medical Treatments □ YES □ NO
2. “How much will I be reimbursed if I see an In‐Network provider?” $__________
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“Do I have an In‐Network deductible?” □ YES □ NO
If YES, “What is my In‐Network deductible?” $__________
Services Authorized
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“Do I need an authorization to receive any of these services?” □ YES □ NO
If YES, “What is my authorization number?” __________________________________
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“How many sessions are authorized?” _____________________________________