Verification of Benefits Form


Prepared by:
Start Time:

Facility Information


Facility: State: Tax Id: NPI:

Subscriber Information


First Name: Last Name: SSN: DOB:

Street: City: State: Zip:

Gender: Email: Phone:

Patient Information


First Name: Last Name: SSN: DOB: Relationship: Gender:

Policy Information


Insurer: Plan Type: Insurer Phone:

Member ID: Group #: Insurance Effective Date: Insurance Expiration Date: Expiry Term:

Pre-Cert Company: Pre-Cert Fax/URL: Pre-Cert Phone:

Carve Out Insurer: BH ID: Carve Out Insurer Phone:

BH Claims Street: BH Claims City: BH Claims Zip: BH Claims State: Payor ID:

Plan Sponsor: Funded: Employer:

Primary: COB on file: Policy Details:

Flags and Limitations


TJC/CARF Required: DTX: RTC: PHP: IOP: RN Required: LVN Required:

In Grace Period: Last Payment: COBRA:

Periodic Maximums: Time Period: Periodic Maximums Details:

Limitations on # of Days: Days Limit Details: Out of State Benefits:

Notification Requirement: Pre-Cert Penalty: Payments Go To: Are AOBs Accepted:

Patient Responsibility


Deductible Applies to OOP: IN and OON Cross Accumulate:

Individual Family N/A
IN OON N/A IN OON N/A
Max Met Max Met Max Met Max Met
Deductible
OOP

Notes: No Max OOP: 4th Quarter Carryover Applies:

Reimbursement


Service Substance Abuse IN Substance Abuse OON Mental Health IN Mental Health OON Co-Pay Notes Telehealth Covered
SAD
AMB
RTC
PHP
IOP
OP
UAs

Rate Table: Rate Table Details: 3rd Part Repricing:

Summary


Summary Notes: