Insurance Verification of Benefits (VOB) Form

Insurance Verification of Benefits (VOB) Form

Please complete this form to verify insurance benefits for ABA services at Arete Behavioral Solutions.
SECTION 1: Client Information

Please provide the client's personal and contact information.
Full Legal Name of Client*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemaleNon-binaryPrefer not to sayOther
Primary Diagnosis (if known)
Parent/Guardian Full Name*

First NameLast Name
Relationship to Client*
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
SECTION 2: Insurance Information

Please provide the insurance policy information.
Insurance Company Name*
Insurance Phone Number (Member Services)*
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Employer (if applicable)
Member ID Number*
Group Number*
YesNo
If no, please list secondary insurance*
SECTION 3: Insurance Card Upload

Upload images of your insurance card (front and back). Accepted file types: PDF, JPG, PNG. Max file size: 20MB each.
Upload Insurance Card – Front*

Cancelof
Upload Insurance Card – Back*

Cancelof
SECTION 4: ABA Service Information (For VOB Call)

Provide details about ABA and other therapy services.
YesNo
Previous Provider Name*
Dates of Service*

MonthDayYear
Date
SpeechOccupational Therapy (OT)Physical Therapy (PT)CounselingOther
SECTION 5: Authorization & Consent

Consent for insurance verification and communication.
Parent/Guardian Signature*
Date*

MonthDayYear
Date
By submitting this form, you acknowledge that the information provided is accurate and authorize Arete Behavioral Solutions to use this information for insurance verification and treatment coordination purposes in accordance with HIPAA regulations.
Should be Empty:

Insurance Verification of Benefits (VOB) Form

SECTION 1: Client Information

SECTION 2: Insurance Information

SECTION 3: Insurance Card Upload

SECTION 4: ABA Service Information (For VOB Call)

SECTION 5: Authorization & Consent