Psychiatric Practice Insurance Verification Form

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Address: ________________________________________________
• Phone: (__) - Email: _________________________

Primary Insurance Information

• Insurance Company: _______________________________________
• Policy Number: _________________________________________
• Group Number: _________________________________________
• Policy Holder Name: ____________________________________
• Policy Holder's Relationship to Patient: ____________________
• Policy Holder's DOB: //___

Mental Health Benefits Verification

• Annual Deductible: $________ Amount Met: $________
• Copayment Amount: $________ per visit
• Number of Sessions Allowed Per Year: ________
• Prior Authorization Required? ☐ Yes ☐ No
• Authorization Number (if applicable): _______________________
• Out-of-Network Benefits: ☐ Yes ☐ No

Covered Services

• Individual Therapy (90834): ☐ Yes ☐ No
• Psychiatric Evaluation (90791): ☐ Yes ☐ No
• Medication Management (99213): ☐ Yes ☐ No
• Group Therapy (90853): ☐ Yes ☐ No

Authorization

I authorize [Practice Name] to verify my insurance benefits and bill my insurance company directly for services rendered. I understand that I am responsible for any charges not covered by my insurance.

Signature: _________________________ Date: //___

For Office Use Only

• Verification Date: //___
• Staff Member: _________________
• Insurance Rep Name: _______________
• Reference Number: _______________