Insurance Authorization Form

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

2

Insured Party's Information(Under whose name is the insurance held)

Employer’s Name

Employer’s Address, City, State, Zip

Employer’s Phone

3

Client’s Information:

Name

SSN

DOB

Legal Sex (as listed on insurance policy)

Relationship to Insured

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

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.

6

Signature* This field is required.

Clear