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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ACCREDiTATiON
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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
Requestor's Email Address
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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