Health Insurance Benefits Worksheet

Therapy Associates, Inc.
HEALTH INSURANCE BENEFITS WORKSHEET
You are responsible for finding out what your health insurance benefits are and keeping track of what your financial responsibility will be for your therapy. Therapy Associates Inc. will file insurance claims for the services you receive, but you are responsible for verifying that your health insurance carrier will cover those services you receive from Therapy Associates Inc.

QUESTIONS TO ASK YOUR INSURANCE CARRIER BEFORE YOUR APPOINTMENT:
Your primary insurance is:
Member #:
Group #:
Member Services Phone #:
Date you called:

MonthDayYear
Date
Who you spoke to:
1. Verify with your insurance company if there would be coverage for the services your child needs:
Speech Therapy
Occupational Therapy
Mental Health Therapy
2. If there is coverage, are there any exclusions?
3. Are there habilitative benefits? (This may determine if therapy will be covered or not)
4. Do I have a co-payment or is there a percentage of the bill I will be responsible for?
5. Does my plan require a deductible be paid for the calendar year before the coverage begins?
If yes, what is the dollar amount?
6. Does my child have an out of pocket maximum that I pay per calendar year?

YesNo
If yes, what is the dollar amount?
7. Does my insurance plan cover only a limited number of sessions for each calendar year?
If so, how many?
Is there a requirement that I get prior authorization and/or a referral/order from my physician before I see a clinician?

YesNo
If yes, who do I contact?
Contact's phone:
Please enter a valid phone number.
I have verified the above information and understand that I am responsible for any charges that the insurance does not cover. Please sign below and submit this form before your evaluation or it may result in a delay in your appointment. Thank you for your cooperation.
Patient Name
Date of Birth

MonthDayYear
Date
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Therapy Associates, Inc. . 904 6+ Ave Ct NE . Isanti, MN 55040 Phone (763) 444-8700 Fax (763)434-0192 Page 1
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Therapy Associates, Inc.

HEALTH INSURANCE BENEFITS WORKSHEET