Patient Information
- Full Name: _________________ Date of Birth: _________________
- Address: _________________ Phone: _________________
- Email: _________________ SSN: _________________
Primary Insurance Information
- Insurance Company: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: _________________
Insurance Verification Details
Benefits Information
- Effective Date: _________________
- Plan Year Deductible: $________ Amount Met: $_________
- Visit Copay: $________ Coinsurance: ________%
- Visit Limit per Year: ________ Visits Used: ________
Authorization Requirements
- Prior Authorization Required? □ Yes □ No
- Auth Number: _________________
- Number of Visits Approved: ________
- Date Range: ________ to ________
OT-Specific Coverage
- CPT Code Coverage:
- 97110 (Therapeutic Exercise): □ Covered □ Not Covered
- 97530 (Therapeutic Activities): □ Covered □ Not Covered
- 97535 (Self-Care Management): □ Covered □ Not Covered
Verification Contact Information
- Date Verified: _________________
- Representative Name: _________________
- Reference Number: _________________
Staff Verification
- Verified By: _________________
- Date: _________________
- Signature: _________________
Note: Benefits verification is not a guarantee of payment. Coverage is subject to patient eligibility at the time of service and plan limitations.