Mental Health Insurance Verification
Client Name
Date of Birth
Insurance Company
Member ID
Group Number
Provider Services Phone Number
Coverage Details
Effective Date
Termination Date
In-Network Deductible
Out-of-Network Deductible
In-Network Co-pay/Coinsurance
Out-of-Network Co-pay/Coinsurance
Session Limitations
Authorization Required?
Yes
No
Authorization Number
Notes