Patient/Date of Birth:______________/_______________/ M__F__

Patient's Social Security #: ___________________________________

Policy Holder/Date of Birth:_________________/_________M__F__

Policy Holder's Social Security #: ______________________________

Name of Carrier: ___________________________________________

Effective (Start) Date: _______________________________________

Type of Product: (PPO/HMO/EAP/EPO/POS):__________________

Special Billing codes? (99404 for EAP's) _________________________

Billing Code Modifiers? (HJ?) _________________________________

Member/Policy ID Number: _________________________________

Group/Plan Number: ______________________________________

Authorization Number (if needed): ____________________________

Number of authorized visits (if relevant):________________________

Beginning/Ending dates of authorizations: __________/___________

Deductible amount/Deductible beginning date:_________/_________

Co-pay amount/visit: _______________________________________

Insurance Co. billing address: _________________________________
________________________________________________________
________________________________________________________

(This is often wrong, since I am a psychologist and bill under Behavioral, not Medical services. Even Insurance Co.'s will give you the wrong address, so have them double check.)

Is there coverage for telecounseling? videocounseling? Yes___/No___/?___

Insurance Telephone (and other numbers):

For Providers/For Members:________________/________________

Insurance Co.'s Electronic Payer ID#:__________________________
(My industry is going electronic, so this number will help me do the
billing for you.)

Insurance Co.'s fax (for submitting billing, if all else fails): __________

Signature. I certify that the above information has been given to me by my insurance carrier and is correct.

___________________________________

Today's Date ________________________

Scan this document and attach it to the special email for this purpose found on the bottom of the this page and also on the telehealth page. Or, copy, print and fax this signed form to:

760.471.1844

onlyformsfordrgriggs@gmail.com