Insurance Information Change Form

Insurance Information Change Form
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
DOB
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Request

MonthDayYear
Date
Provider Name
NEW Insurance Information- Insurance Company Name
Subscriber/Policy Holder Name (if different from client)
Relationship to Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Insurance ID Number
Group Number
Employer (if applicable)
Effective Date of New Insurance

MonthDayYear
Date
Please upload a copy of the front of your updated insurance card

Cancelof
Please upload a copy of the back of your updated insurance card

Cancelof
Important Information Regarding Insurance Changes

To ensure accurate billing and avoid unexpected charges, reVIBE Mental Health must verify your new insurance benefits and your provider's participation before services can be billed to your new insurance plan.

Please note:

-Verification of benefits does not guarantee payment by your insurance company.

-Even if reVIBE Mental Health participates with your insurance plan, your individual provider may not be contracted or credentialed with that insurance carrier.

-Insurance companies determine eligibility, benefits, authorization requirements, and network participation.

-Claims submitted before insurance verification or provider credentialing may be denied, and you may be financially responsible for those charges.

Because of this, appointments cannot be billed to your new insurance until verification has been completed.

During the Verification Process

Until your new insurance has been verified, one of the following will occur:

I elect to continue receiving services and understand my appointments will be billed at the practice's current self-pay rates until insurance verification is complete. Self-pay rates start at $120.

OR

I elect to postpone future appointments until reVIBE Mental Health confirms my insurance benefits and my provider's network participation.

Patient Acknowledgment

I understand and acknowledge that:

-I am responsible for notifying reVIBE Mental Health whenever my insurance coverage changes.

-Insurance verification may take several business days and, in some cases, additional time if provider credentialing or payer confirmation is required.

-My provider must be individually participating with my insurance plan before services can be billed as in-network.

-Even if the clinic participates with my insurance company, my treating provider may not be contracted or credentialed with my specific insurance plan.

-If I choose to receive services before insurance verification is completed, I agree to pay the applicable self-pay charges at the time services are rendered.

-If my insurance company later determines services are covered and payment is received, any applicable overpayment will be refunded or credited to my account in accordance with reVIBE Mental Health's billing policies.

-I understand that reVIBE Mental Health cannot guarantee insurance coverage or payment for services.
Patient election
Name of Client
Date

MonthDayYear
Date
Signature of client/parent/guardian
Should be Empty: