INSURANCE INFORMATION
INSURANCE INFORMATION
PRIMARY INSURANCE COMPANY: _____________________________________________________
INSURANCE ADDRESS: ________________________________________________________________
CUSTOMER SERVICE PHONE NUMBER ON BACK OF CARD: ______________________________
POLICY HOLDER’S NAME: ____________________________ BIRTH DATE:____________________
MEMBER ID NUMBER:__________________________________
GROUP NUMBER: __________________
POLICY HOLDER’S SOCIAL SECURITY NUMBER: ________________________________________
VERIFICATION OF INSURANCE BENEFITS: (Call # on back of your insurance card and ask the below questions. What is the # you called? _________________. Please ask for the name of the person you spoke to: ___________).
1. Is my mental health benefits covered by a different insurance company? Yes No
2. If different, please use the below secondary insurance area to clarify the name, phone number and Policy number.
3. Do I require any authorization or referral to see a clinician at the 536 Bienville address? YES NO If yes, please include authorization # here ____________.
4. What is my deductible? ____What amount of the deductible have I met? _____ What month each year does my annual deductible begin? __________________.
5. What is my copay per visit? _______.
6. How many sessions per year are allowable under my plan? _______________.
SECONDARY INSURANCE COMPANY: _________________________________________________
ADDRESS/PHONE: _____________________________________________________________________
POLICY HOLDER’S NAME: ____________________________ BIRTH DATE:____________________
POLICY NUMBER: __________________________________ GROUP NUMBER: _________________
POLICY HOLDER’S SOCIAL SECURITY NUMBER: ________________________________________
ASSIGNMENT OF INSURANCE BENEFITS
In regards to services rendered to me by the provider listed below, I, _______________________________ authorize the insurance company(s) listed above to pay medical benefits directly to W. Scott Griffies M.D, In the event that coverage is denied or charges are applied to deductible, I agree to assume full financial responsibility for the charges incurred. Furthermore, I authorize Dr. Griffies to release any or all information contained in my medical file to the above listed company(s) for the purposes of obtaining authorization and/or billing procedures.
PATIENT NAME (PLEASE PRINT): _______________________________________________________
PATIENT’S SIGNATURE: _______________________________________________________________
DATE: ___________________________ WITNESS: __________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
Related searches
- five components of information systems
- 5 types of information systems
- watershed information for kids
- best stock information website
- philosophy of information technology
- latest invention in information technology
- key components of information system
- why is information so important
- why is information technology important
- why is information valuable
- the importance of information systems
- why are information systems essential