Resource Education Center Co.

INSURANCE VERIFICATION FORM-PHONE INTAKE

Referred by: __________________

Services: Testing / Assessment Counseling Individual/Group

Other:

___________________
Patient Name: ____________________________________________ DOB:

____ / _____ /_____________ age _____

Address: ___________________________________________________________Phone ____________________________

Subscriber: _________________________________ Relationship: ________________ Subscriber DOB: ______________
Insurance Company: ________________________________ Policy/ID:___________________________________________
Insurance Phone: __________________________________ Insurance Phone: ____________________________________
Is there another health benefit plan? N Y ID#:______________________________________ Primary: _______________
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Effective date: ___ / ____ / _____________ to ___ / ____ / ______________
CALENDAR YEAR // PLAN YEAR
# Units
$ Liability Deductible Amt Met?
Authorization Required?/Number# Effective Dates
H0001________

________

$_________ $_________

No Yes ____________________

_________________

H0004 ________

________

$_________ $_________

No Yes ____________________

_________________

H0005 ________

________

$_________ $_________

No Yes ____________________

_________________

_____ ________

________

$_________ $_________

No Yes ____________________

_________________

_____ ________

________

$_________ $_________

No Yes ____________________

_________________

Additional Information: _________________________________________________________________

____________________________________________________________________________________________________
____________________________________________________________________________________________________
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*Exclusions: No Yes (specify) ___________________________________________________________________________
*Pre-existing conditions No Yes (specify)_______________________________________________________________

Claims Address: _______________________________________________________________________

Spoke to: _____________________________________

Verified by: ______________ Date: _________________

*Deductible Reminder (specify date) _______________________ *Address provided (specify date):________________

APPOINTMENT: Date: _________________________________

Time: _______________

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BILLING STATUS
CPT

Date of Service

Units

Dx

Bill Date By/Method Units Pd Denied/Paid

H0001

____________

_____

______

_______ __________

______

____________

H0003

____________

_____

______

_______ __________

______

____________

H0005

____________

_____

______

_______ __________

______

____________

________

____________

_____

______

_______ __________

______

____________

________

____________

_____

______

_______ __________

______

____________

 Auth.Sub. Auth obtaind Auth obtaind addl Entered Sys Test Compl. Rpt Compl Billing Compl. Closed

TELEPHONE INTAKE/REFERRAL
Client Name: ____________________________________ Referred By: _________________________________________
Initial Call Date: ____________________ First Contact Date: ____________________
Caller:

____________________________________ Relationship : parent child spouse therapist doctor ____________

Phone: _____________________________________
Treatment requested: ____Testing

_____Counseling

Okay to leave a message? Yes

No

_____ Unsure _____Other : _____________________________

Presenting Concerns: _________________________________________________________________________________

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Additional Comments: ________________________________________________________________________________
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