This information is provided as a courtesy so you can check your benefits.

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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:

1. “Do I have mental/behavioral health coverage?” □ YES □ NO 

   2. “Do I have Out‐of‐Network benefits?” □ YES □ NO 

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Out‐of‐Network Benefits

1. “How much will I be reimbursed if I see an Out‐of‐Network provider?” $__________ 

2. “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 

1. “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?” $__________ 

1. “Do I have an In‐Network deductible?” □ YES □ NO 

If YES, “What is my In‐Network deductible?” $__________ 

 

Services Authorized 

1. “Do I need an authorization to receive any of these services?” □ YES □ NO 

If YES, “What is my authorization number?” __________________________________ 

1. “How many sessions are authorized?” _____________________________________