Insurance provider questionairre

We have created this form to help get the most information from your insruance provider.

Pediatric Occupational, Physical, Speech and Language, Educational and Behavioral Therapies 931-372-2567 toll free 1-877-372-2567 www.developmentaldelay.net email covd@covd.biz Verification of Insurance and Eligibility/Benefits
 Name of Patient: ____________________________________
Patient date of birth: __________________________________
Name of Insured: ____________________________________
Insured date of birth: _________________________________
Name of Primary Insurance: ___________________________
Identification number: _____________________________________
 Name of Secondary Insurance: ___________________________________
Identification number: __________________________________________
Phone number of primary insurance: ______________________________
Name of person you called: ______________________________________
 Is Center of Development in your network? (circle) YES     NO
If NOT, do you have out of network benefits? (circle) YES NO
Effective date on this policy: _____________________________________
Do you have outpatient occupational therapy benefits? YES NO
If yes, how many visits per calendar year? __________________________
Does outpatient occupational therapy require pre authorization? (circle) YES NO
What percentage do you pay after deductible is met? _________________
What is the amount of the deductible/out of pocket? Individual:______________Out/Pk:_______________________
Family: _______________________ Out/Pk: _______________________
What is the amount that has been applied toward the deductible?
Individual: ______________Out/Pk: _______________Family: ____________  Out/Pk:__________    Lifetime Maximum: ____________________________________________
Are there any pre-existing clauses on this policy? YES NO