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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: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 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