Insurance Verification Request

Upon completion of this form, it will submit to Crystal, Jenny and LaRhonda. Use this form for all new clients that have uploaded their insurance card (front and back) to the client portal documents.

Client Name and DOB

Insured Name and DOB (if the same, type: same)

Date of First Appointment

Clinician

Please collect debit card at first session

Verification Type

Therapy

Supervisory Billing

Medication Management

Group Therapy Pre Authorization

These items must be complete PRIOR to sending this form to Resolve Billing and confirming client's first appointment.

Insurance Card Uploaded to Therapy Notes (front and back)

Insurance Card in Billing Settings To Therapy Notes (patient has insurance box)

Front Of Insurance Card

Add file

Please upload a file

Back Of Insurance Card

Add file

Please upload a file

Resolve Billing please upload the information to the client's chart on the comments of the billing settings in this format. Thank you!

Deductible: $_______ - $_______ met
Out of Pocket Max: $_______ - $_______ met

After deductible is met, the insurance covers __% of the below contracted rates. So your cost would be __% of the below contracted rates.

With this, the therapy sessions will cost the following: Intake (90791): $
30 min (90832): $
45 min (90834): $

60 min (90837): $
60 min crisis (90839): $
50 min family (90847): $
50 min family w/o (90846): $
Name of Rep and reference number:

Once this information is uploaded, the therapist needs to email the client their therapy costs in this format. And let them know they can email me if they have any questions. Thank you!

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