406 S First St., Suite 308
Mount Vernon, WA., 98273
Phone: (360) 424-0400
Fax: (360) 336-3270

Determining Your Insurance Benefits

Dear Prospective Client,

Insurance Benefits vary widely, and it can be difficult and confusing trying to determine your coverage. Unfortunately, you are ultimately responsible for your health care costs, regardless of insurance coverage. We do not want you to be surprised by any unexpected costs.

Therefore, we have designed this section of our website to help guide you through the process of verifying your insurance coverage. It is important that you contact your insurance carrier prior to your first mental health appointment to make sure that you understand your current coverage for outpatient mental health services.

First, print out this page and fill in as much information as you can prior to calling your insurer.

Identifying Information

Your Name _______________________________
Client Name (If different)________________________________________
Your relationship to client __ self __ spouse/partner ___parent ____ other: ___________
Client birthdate ______________
Mailing Address__________________________________________________________
Home Phone____________Work Phone_______________Cell Phone______________
Marital Status________________________Custody Status(if a child)________________
Name and address of non-custodial parent, if applicable
________________________________________________________________________
Employer/School ____________________________________

Primary Insurance Co.*

Name & policy#____________________________________
Your insurance ID #______________________Group #____________________
Insurance Billing Address_________________________________________________
Ins. Tel. # _______________________________
Name of Insurance Subscriber ___________________Subscriber's Date of Birth_______
Subscriber Address (if different from above)
__________________________________________________ tel# _________________
Subscriber's Employer_____________________________________________________

Secondary Insurance Co.

Name & policy#____________________________________
Your insurance ID #______________________Group #____________________
Insurance Billing Address_________________________________________________
Ins. Tel. # _______________________________
Name of Insurance Subscriber ___________________Subscriber's Date of Birth_______
Subscriber Address (if different from above)
__________________________________________________ tel# _________________
Subscriber's Employer_____________________________________________________

Now, before phoning your insurer, please get yourself a cup of tea or hot chocolate, and take a deep breath and put on some relaxing music! This could be a frustrating half hour!

Now, phone the telephone number on the back of your insurance card. If they do not list a telephone number for "Behavioral Health" or "Mental Health," try the number listed for "Medical."

Once you get a human being, ask the following questions and write down the answers on this form.

QUESTIONS TO ASK YOUR INSURER IN ORDER TO DETERMINE ELIGIBILITY, BENEFITS AND YOUR RESPONSIBILITIES:

Is my mental health benefit current? Are any diagnoses excluded from my benefit? _______________________Are family and marital therapy covered? _____________

Does my insurer require that I see a provider who is contracted with my insurer?

If so, is the therapist I want to see on your approved panel? ___Yes ___No. If not, what are the names of local providers on your panel?

Are there any requirements for prior approval? ___yes___no If so, what must I do?

Approval obtained? ___Yes ___No If yes, for how many sessions? ________________

Total number of sessions allowed per year: ___

Yearly deductible for each individual $___ deductible for family $____

Amount of yearly deductible still unmet $______

Per session co-pay due at time of service $____

What percentage of my allowable is paid by my insurance? ______ Other co-insurance that is my responsibility? ______________________________

Maximum # of sessions: _______ or dollar limit on my benefit: ________________

* Note: Some clients have a "secondary" insurance which pays all or part of the remainder after the "primary" has paid. Usually we can simply submit the Explanation of Benefits from the Primary to trigger the remaining payment from the Secondary, but you may want to contact your secondary insurer to make sure that they do not have additional regulations.

Please be sure to keep a copy for your records and bring a copy for your therapist at the first visit. All information will be kept confidential in accord with HIPPA and Washington State Law. (link to Confidentiality and Privacy Practices)

Please remember that insurance is often complicated and confusing for both clients and providers. In some case it may not be possible to have a complete understanding of your coverage prior to actually getting an "Explanation of Benefits" back from your Insurance company after billing. However, your phoning your insurer and asking the questions above should greatly reduce unexpected and unwelcome surprise costs.

Some clients prefer to pay for services themselves, due to lack of insurance or to privacy concerns. If this is your preference, please discuss this with your therapist.

Payment Plan_________________________Person Responsible____________________

Signature __________________________________ Date ________________________