Blue Mountain TMS Insurance Benefits Investigation Form

Insurance Benefits Investigation for TMS Therapy
TMS therapy is covered by many health insurers, including Medicare. Completing the required information in this form will allow us to give you the most current status of your insurance coverage benefits for TMS therapy.

Our team will begin immediately upon your completion.

(This form is HIPAA compliant and we pride ourselves in managing your health care in a respectful, concise and timely manner. )
Please complete this contact information. All insurance companies require we validate our inquiry with specific contact information.
Full Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your Phone Number *

Area Code Phone Number
What is your Date of Birth? *

Month Day Year
This is required for benefits verification.
Please provide your email.
example@example.com
This section is about your healthcare insurance information.
Are you the primary healthcare insurance holder? *

Yes No
Who is the primary insurance card holder?

First Name Last Name
Who is your healthcare insurer? *
Blue Cross Blue Shield, Aetna, Beacon, Tricare, MEDICARE
What is your Healthcare ID? *
This is usually listed on the front of your card.
Healthcare Insurance phone number.
This is often listed on the back of your insurance card. Look for a provider or mental health number.
You have just received a request TMS Benefits Investigation from {pleaseProvide}. You should prioritize this by either completing the BI immediately or letting the participant know that you have received this.

To assist here is the information you will need to share.

Our Clinics Name: Blue Mountain Psychiatry

Provider Number: Tax ID Number:

Provider Type:

Our Address:

Phone Number:

Services to Verify:

Consultation: 90792.

TMS Therapy: 90867, 90868, 90869.
Here's an area for you to record details of {pleaseProvide} Benefits Investigation.

Contact: ___________________________Date of Call: ________________

Call Reference Number: __________________

Insurance Carve Out: ____________________ Direct Phone: _______________

{pleaseProvide} {yourPhone}
Should be Empty:

Insurance Benefits Investigation for TMS Therapy