COMMERCIAL ELIGIBILITY FORM

 

    BC/BS ____         Harvard Pilgrim ____         Tufts ____          UBH ____      *Other ____         

 

Client:___________________ Date:______________

 

Inpatient: ________   Outpatient: ____________

Patient: _____________________________________

Policy #: ________________________________

 

Listed on Policy: _____________________________

*Insurance Co.: ____________________________

 

Type of Policy: Indiv. _________________________

                          Family________________________

Copay:  _________________________________

 

Deductible: Indiv. ____________  Met? ___________

                    Family___________   Met? ___________

                    None _____________

 

Subscriber: ______________________________

 

Policy Effective Date:______________________

Therapist Restrictions? ________________________

 

___________________________________________

Visits/year: ______________________________

 

Visits Auth: ______________________________

 

Authorization #: __________________________

 

Date Range: _____________________________

 

Treatment Plan: ___________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Date Received:  _____________Confirmed: ________

Contact: ____________________________

 

Eligibility Done By: _________________________

Tel #:  ____________________________

 

 

Faxed Back:    YES ________  NO ________

Called Back:   YES ________  NO ________

Yellow Mailed: YES _______  NO ________