Patient Information
- Full Name: _________________________ Date of Birth: //___
- Address: ________________________________________________
- Phone: _________________ Email: _________________________
- Primary Care Physician: ___________________________________
Insurance Information
Primary Insurance
- Insurance Company: _______________________________________
- Policy Number: _________________________________________
- Group Number: _________________________________________
- Policyholder Name: _____________________________________
- Policyholder DOB: //___ Relationship: ________________
Benefits Verification (Office Use Only)
- Date Verified: //___
- Representative Name: ____________________________________
- Reference Number: ______________________________________
Coverage Details
- Speech Therapy Coverage: □ Yes □ No
- Prior Authorization Required: □ Yes □ No
- Number of Sessions Covered: _____________________________
- Calendar Year Maximum: ________________________________
- Deductible: $__________ Amount Met: $__________
- Copay Amount: $__________ Coinsurance: _________%
- Coverage Period: ______________________________________
Authorization Information
- Authorization Number: __________________________________
- Number of Visits Authorized: _____________________________
- Authorization Valid From: //___ To: //___
- CPT Codes Approved: __________________________________
Additional Notes
Verification Completed By
- Staff Name: __________________________________________
- Signature: ________________________ Date: //___
Note: This verification of benefits is not a guarantee of payment. Benefits are subject to all plan terms, limitations, and conditions in effect at the time services are rendered.