Behavioral Independence, Inc. Insurance Paperwork

Behavioral Independence, Inc.

Insurance Verification Form
Client Information
Client Name

First NameLast Name
Date of Birth
Preferred Language
Translation Accommodations Required
Parent/Guardian Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Information
Name

First NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation to client

ClientParentGuardianSpouse/Partner
Gender

MaleFemale
Insurance Carrier
Insurance Carrier’s Phone #

Area CodePhone Number
Member Identification #
Group Identification #
Secondary Insurance Information
Is there a secondary?

YesNo
Name

First NameLast Name
Date of Birth
Relation to Client

ClientParentGuardianSpouse/Partner
Gender

MaleFemale
Insurance Carrier
Insurance Carrier's Phone #

Area CodePhone Number
Member Identification #
Group Identification #
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Behavioral Independence. I understand that I am financially responsible for any balance. I authorize Behavioral Independence or my insurance company to release any information required to process my claims.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Insurance Card Front & Back

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Cancelof
Parent/Guardian Driver's License

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Cancelof
ABA Referral

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Cancelof
Diagnosis Report

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Cancelof
Additional Documentation

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Cancelof
Should be Empty:

Behavioral Independence, Inc.

Client Information

Primary Insurance Information

Secondary Insurance Information