Insurance Benefit Worksheet printable pdf download

Insurance Benefit Worksheet

INSURANCE BENEFIT WORKSHEET

Please use this form as you speak to your health insurance’s customer service

representative when verifying physical therapy coverage.

Your Plan Information: This information is found on your insurance card.

Insurance plan name or program name: _______________________________

Member ID number: __________________Group number: ________________

• Customer Service phone number (w/area code) _________________________

• Name of customer service representative: _____________________________

• Insurance claim address: ___________________________________________

• Date eligibility began: ________________________

• Deductible: $_________Co-pay: $__________Co-insurance: $________

• Maximum allowable benefit for physical therapy: $______ or # visits ________

• Remaining $_________ # visits ________ for current year as of ____________

• Is my physical therapist a PREFERRED PROVIDER for my plan?

yes

• If your company is an HMO or PPO, and we are NOT a provider for the plan, what is the

benefit coverage for Velocity Physiotherapy.? (i.e., 60%, 80%, etc.).

• Does this plan require a prescription or referral for PT services?

yes

• Does this plan require pre-authorization for physical therapy?

yes

If you have any questions please call Susy at (877) 461-9918 or email

Insurance Benefit Worksheet