Out-of-Network Insurance Verification Sheet
Client Information
| Name |
|
Date of Birth |
|
| Phone Number |
|
Email |
|
Provider Information
| Provider Name |
|
NPI |
|
| Tax ID |
|
Service Address |
|
Insurance Information
| Insurance Company |
|
Phone Number (Provider Line) |
|
| Subscriber Name |
|
Member ID |
|
| Group Number |
|
Relationship to Subscriber |
|
Benefits Information
| Does policy cover out-of-network? |
|
| Deductible (Individual/Family) |
|
| Deductible met? |
|
| Coinsurance after deductible |
|
| OON Out-of-pocket max |
|
| Preauthorization required? |
|
| Number of sessions/year allowed |
|
| CPT Codes covered (90791, 90837, etc.) |
|
| Rate of reimbursement (allowed amount) |
|
| Claim Submission Address / Fax |
|
| Other notes/requirements |
|
Representative Information
| Date Called |
|
Reference number |
|
| Spoke With |
|
Additional Notes