Deb VOB - RESIDENTIAL MENTAL HEALTH TREATMENT | DEPRESSION AND ANXIETY

Insurance Provider *

Insurance Provider Phone Number *

Insurance ID *

Name of Policy Holder

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Last

Policy Holder's Date of Birth *

Policy Holder's Relationship to Person Needing Healing *

Address of Policy Holder

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Address Line 2

City

State

Zip Code

Report Policy Benefits for:

Type of Benefit:

Additional Notes

Insurance Card (Front)

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Insurance Card (Back)

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I have read and agree to the DISCLAIMER below. *

Health Insurance Benefits/Coverage/Authorizations DISCLAIMER

As a courtesy, we will attempt to verify your health insurance benefits and/or necessary authorizations for you. Please be aware, this is only “A QUOTE of Benefits/Authorizations.” We cannot guarantee payment or verify that definite eligibility of benefits conveyed to us or to you by your carrier will be accurate or complete. Payment of benefits are subject to all terms, conditions, and exclusions of the member’s contract at the time of service. Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” Our office will make every effort to bill your insurance in a timely manner. If your carrier determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service and it will become your responsibility. We recommend you to be familiar with and verify your benefits with your insurance company prior to your services with us. Please be aware, that even then, it is still not a guarantee of benefits or payment.

By signing this authorization, I authorize my healthcare provider and my health insurance company to use and/or disclose protected health information (PHI) such as my name, address, date of birth, medical information on my condition, and insurance information from my health records and insurance information to TWI and any of its contractors as necessary to research insurance coverage. I understand that the information used or disclosed under this authorization may be shared with other people or entities and may no longer be protected by federal privacy regulations. In carrying out these activities, TWI, and its contractors may relay information to health insurer(s), receive information from health insurer(s), and communicate such information to my healthcare provider. I understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that my refusal to sign does not affect payment for services, my ability to obtain treatment, or my eligibility for benefits. I understand that if I choose to cancel (revoke) this authorization, I must do so in writing to my healthcare provider. However, I cannot cancel actions that have already been taken by relying on my authorization. This authorization will expire one (1) year after the date it is signed below.

If your insurance plan does not pay within 120 days of treatment, you must pay any outstanding balance and seek reimbursement from your level of service.