Information You will Need for the call:

Client's Name:_______________________________________

DOB:_____________________________

Policy Holder's Name (if not client):_____________________________

DOB Policy Holder:________________________

Member ID# (Note Mental health may have a different # from medical health coverage):________________________________________________

Questions For Your Insurance Provider

Do I have mental health coverage?

 yes

 no

Benefits

What is my co-pay amount? (You will need to pay this amount for each visit)__________________

Do I have a deductible? (this is the amount you pay before your insurance starts paying)

 yes

 no

If "yes", what is my deductible?_____________

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Please verify that the following services are covered under your policy:

Psychiatric Diagnostic Evaluation (CPT Code 90701)

yes

no

Individual therapy (CPT Code 90834)

 yes

 no

Individual/Couples/Family Therapy (CPT Code 90837)

 yes

 no

Group Therapy (CPT Code 90853)

 yes

 no

Services Authorized

Do I need an authorization to receive any of these services?

 yes

 no

How do I get authorization?___________________________________________________________________________________________________________________________________