Verify Benefits
Verify Benefits
WE OFFER A VARIETY OF DiFFERENT SERViCES.
ARE YOU:
A PATiENT OR FAMiLY MEMBER
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AN OWNER OR LEADER OF A GROUP OR INDiViDUAL PRACTiTiONER?
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AN OWNER OR LEADER OF A FACiLiTY OR LiCENSED PROGRAM?
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JUST LOOKiNG FOR CONSULTiNG/ iN HOUSE BiLLiNG OR CLiNiCAL TRAiNiNG SERViCES?
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PATiENT OR FAMiLY MEMBER
AN OWNER OR LEADER OF A GROUP OR INDiViDUAL PRACTiTiONER?
AN OWNER OR LEADER OF A FACiLiTY OR LiCENSED PROGRAM?
JUST LOOKiNG FOR CONSULTiNG/ iN HOUSE BiLLiNG OR CLiNiCAL TRAiNiNG SERViCES?
PATIENT OR FAMILY MEMBER
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An Owner or leader of a group or individual practitioner
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AN OWNER OR LEADER OF A FACILITY OR LICENSE PROGRAM?
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JUST LOOKiNG FOR CONSULTiNG/ iN HOUSE BiLLiNG OR CLiNiCAL TRAiNiNG SERViCES?
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Verification of Benefits
Facilities or Families – To obtain a Verification of Benefits, complete this form:
Verification of Benefits (#1)
Patient First Name
Patient Last Name
Is the patient 18 yrs or older?
- Select -
Yes
No
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Phone Number
Parent/Guardian Email Address
Patient Phone Number
Patient Email Address
Requestor's Email Address
Date of Birth
Level of Care Needed
Detox
PHP (Partial Hospitalization)
RTC (Residential Treatment)
IOP (Intensive Outpatient)
Other
Requestor's Phone Number
Requested Facility Name
I declare that the info I’ve provided is accurate & complete.
Insurance Carrier Name & ID #
Today's Date
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All Services
Patient & Family Services
Group or Individual Provider Services
Facility or Licensed Program Services
Consulting & Other Specialized Services
CREDENTIALING / PAYOR CONTRACTING SERVICES
All Services
Patient & Family Services
Group or Individual Provider Services
Facility or Licensed Program Services
Consulting & Other Specialized Services
CREDENTIALING / PAYOR CONTRACTING SERVICES
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