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Insurance Authorization Form
6
Questions
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1
Insured Party’s Information:
*
This field is required.
(Under whose name is the insurance held)
Name (as on insurance policy)
SSN
DOB
Legal Sex (as listed on insurance policy)
Phone Number
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2
Insured Party's Information
(Under whose name is the insurance held)
Employer’s Name
Employer’s Address, City, State, Zip
Employer’s Phone
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3
Client’s Information:
Name
SSN
DOB
Legal Sex (as listed on insurance policy)
Relationship to Insured
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4
Policy Information
Company Name
Behavioral Health Member Services Phone
Insurance/Member/Employee ID
Group No.
Is Behavioral Health Managed By Another Company? If Yes, What Company
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5
By signing this form:
I authorize the release of any medical or other information necessary to process claims on my behalf.
I authorize payment of government or commercial medical insurance benefits to The Resilience Group.
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6
Signature
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This field is required.
Clear
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