INSURANCE VERIFICATION FORM

Randall R. Lyle, Ph.D., LMFT, BCIA-EEG
1120 2nd Ave. SE
Cedar Rapids, IA 52403
319-261-2291 Office, 319-538-0196 Fax

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Patient's name
Patient's date of birth
Patient's insurance ID number:
Insurance carrier phone number
Carrier name
Effective date of policy
Carrier name that is responsible to process claim
Claims address for the carrier that is responsible to process mental health claims
   
Date of verification
Visits allowed per year
Co-payment amount per visit
Deductible
Life Time Maximum (LTM)
Out of Pocket (OOP)
Authorization number required
Insurance coverage
 

Procedure Name

CPT

Benefits

Note

Initial 90791


Individual 90834
Psychophysiological 90876
Family without patient 90846
Family with patient 90847
Biofeedback any modality 90901