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:

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

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

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?” _____________________________________

 Treating patients psychiatry psychiatric for maternal mental health for perinatal mood and anxiety disorders (PMADs) postpartum depression anxiety bipolar disorder OCD PTSD birth trauma through telemedicine telehealth video with medication management, therapy, birth and postpartum planning in around and near Champaign Elgin Naperville Oak Park Bolingbrook Aurora Wheaton Joliet Orland Park Chicago Palatine Arlington Heights Tinley Park Springfield Schaumburg Normal Mount Prospect Waukegan Hoffman Estates Oak Lawn Skokie Des Plaines Rockford Cicero Bloomington Berwyn Peoria Decatur or anywhere in Illinois