Insurance Verification | Karen Buckley

Please note: You are responsible to know and verify your benefits prior to any services. It is also your responsibility to notify the office of all changes in your insurance. Please have your insurance card available at your appointment as we will need a copy.

Complete the below insurance Information

First Name

Last Name

Date of Birth

Address

City

State/Province

Zip/Postal

Phone

Are you the primary on the insurance?

yes

First name of Primary

Last name

Date of birth of primary

Insurance information

Insurance company name

Insurance Policy or ID number

Insurance group number

Insurance phone number

Do you have a secondary insurance

Yes

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Complete the below insurance Information

First Name

Secondary insurance compay name

Last Name

Date of Birth

Secondary insurance Policy or ID number

Address

City

State/Province

Zip/Postal

Phone

Secondary Insurance Policy or ID number

Are you the primary on the insurance?

yes

First name of Primary

Secondary insurance group number

Last name

Date of birth of primary

Secondary Insurance phone number

Insurance information

Insurance company name

Benefit Information

Insurance Policy or ID number

Insurance group number

Number of approved visits

Insurance phone number

Do you have a secondary insurance

Yes

Do you have a Deductible?

yes

Amount of Deductable

How much of Deductable has been met?

Do you have a Co-Pay?

yes

Amount of Co-Pay

Do you need a Referral for counseling?

yes

If yes, you are responsible for obtaining that.

Did you confirm that Karen M. Buckley, LICSW, ACSW, OSW-C is covered by your insurance?

yes

In or out of network?

yes

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Insurance Verification Form

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