A PSYCHOLOGICAL CORPORATION
PSY 8534

 
line decor
  
line decor

 
 
 

 


 

 

 

 

Home Page
E books
Offices
Insurance Info


Humor
Blog
Relationship Survey


Reciprocal Links
Sitemap


Sitemap
Other Books

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


INSURANCE INFORMATION

 

Patient/Date of Birth:______________/_______________/ M__F__

Patient's Social Security #: ___________________________________

Policy Holder/Date of Birth:_________________/_________M__F__

Policy Holder's Social Security #: ______________________________

Name of Carrier: ___________________________________________

Effective (Start) Date: _______________________________________

Type of Product: PPO/HMO/EAP/EPO/POS):__________________

Special Billing codes? (99404 for EAP's) _________________________

Billing Code Modifiers? (HJ?) _________________________________

Member/Policy ID Number: _________________________________

Group/Plan Number: ______________________________________

Authorization Number (if needed): ____________________________

Number of authorized visits (if relevant):________________________

Beginning/Ending dates of authorizations: __________/___________

Deductible amount/Deductible beginning date:_________/_________

Co-pay amount/visit: _______________________________________

Insurance Co. billing address: _________________________________
________________________________________________________
________________________________________________________

(This is often wrong, since I am a psychologist and bill under Behavioral, not Medical services. Even Insurance Co.'s will give you the wrong address, so have them double check.)

Is there coverage for telecounseling? videocounseling? Yes___/No___/?___

Insurance Telephone (and other numbers):

For Providers/For Members:________________/________________

Insurance Co.'s Electronic Payer ID#:__________________________
(My industry is going electronic, so this number will help me do the
billing for you.)

Insurance Co.'s fax (for submitting billing, if all else fails): __________

Signature. I certify that the above information has been given to me by my insurance carrier and is correct.

___________________________________

Today's Date ________________________