Insurance

Preliminary Health Insurance Information

We realize that with a patient in crisis with a severe illness, managing some of the details related to accessing care can be overwhelming. The following form has been designed to garner information you may have so that we can be as effective as possible at fully researching your healthcare benefits on your behalf. You may not know all of the answers to the questions – and that is okay. Simply fill in what you can. Along with this form, please send a copy of the front and back of the insurance policy card and the pharmacy benefits ID card under which the patient is covered.

*Required

Policy Holder’s Name:*

Please enter name as it appears on the policy-card

Policy Holder’s Email Address:*

Policy Holder’s Phone Number:*

Policy Holder’s Date of Birth:*

Policy Holder's SSN:*

###-##-####

Patient Information

Patient's Name:*

Enter name as it appears on the policy-card

Patient's Date of Birth:*

Patient's SSN:*

###-##-####

Insurance Information

Name of Primary Insurance Company:*

Phone Number for Provider Services:*

Subscriber ID:*

Member Number (if different from Subscriber ID):

Group Number:

Dependent’s ID Number (if listed on the card):

Insurance Information

Name of Behavioral Health Carrier:*

Sometimes, behavioral health services are administered by companies different from primary medical health insurance entities

Phone Number of Behavioral Health Carrier:

This field may be left blank

Policy Holder’s Employer:*

Plan Type:*

PPO HMO POS Unknown

Other:

Insurance Card Image:

No File Chosen

File uploads may not work on some mobile devices.

scanned copy of front & back of insurance policy card

Insurance Information

Name of Pharmacy Benefits Provider:

Do you have a secondary insurance?

Yes No

Name of Secondary Insurance Company:

Do you have Medicaid or Medicare?

Yes No

I have:

Medicaid Medicare

Subscriber ID:

Phone Number for Pharmacy Benefits Services:

This field may be left blank

Insurance Card Image:

No File Chosen

File uploads may not work on some mobile devices.

scanned copy of front & back of insurance policy card

Completion

By submitting this form, you authorize Veritas Collaborative to contact the insurance company indicated on this form in order to verify health benefit information for the purpose of obtaining services provided by Veritas Collaborative for treatment eating disorder treatment.

By typing my name in the box below, I certify that to the best of my knowledge the statements contained in this form are true.

Name of Policy Holder:*

First Name

Last Name

Date Completed:*

MM/DD/YYYY

Progress