Download Insurance Verification - Balance Womens Health

Thank you for your interest in our clinic. We look forward to meeting you!
We have enclosed this insurance verification form for your convenience. We recommend that you contact your insurance
company by using the number on your insurance card and ask the questions listed below and fill in the information on this
form. This form was generated to help you better understand your insurance policy and coverage.
Insurance Company: __________________________
Phone: _________________________________
Spoke To: ___________________________ Date: __________ Time: ___________
Patient Name: ___________________________
Policy Holder Name: __________________________
Date patient became effective on policy: __________
Psychiatrist Office Visit will be covered by (please circle):
Co-Pay
Deductible and Co-Insurance
Co-Pay $________
Co-Insurance: In-Network % ______
Co-Insurance: Out-of-Network % ______
Individual Deductible
$________
Individual Deductible Amount Met
$ ________
If applicable, Family Deductible
$ ________
Family Deductible Amount Met
$ ________
Out-of-Pocket Individual Amount
$ ________
Out-of-Pocket Amount Met
$ ________
If applicable, Family Out-of-Pocket
$ ________
Family Out-of-Pocket Amount Met
$ ________
How will my insurance policy cover a mental health new patient office visit (CPT 99205)?
________________________________________________________________________________________________
How will my insurance policy cover a mental health follow-up office visit (CPT 99215)?
________________________________________________________________________________________________
Notes:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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The items listed on the attached sheet are only an example of the codes that may be billed in our office. Payment is due at
the time of services. Dr. Dalthorp is on many insurance panels and will bill your insurance for services. You are
responsible for copays, deductibles, and services your insurance does not cover. Additionally, some insurance policies
require authorization for visits before you are seen in our office. While we may assist with this, it is ultimately the
patient’s responsibility to ensure that all forms and authorizations are obtained prior to the initiation of treatment.
1105 SW 30th Ct. Moore, OK 73160
Phone: (405) 378-2727
Fax: (405) 378-2776