PROVAIL Therapy Services Application 05 2015 1

PROVAIL Availability/ Insurance Verification Worksheet Thank you for choosing PROVAIL for your Speech or Occupational Therapy. Once we have received the completed new intake packet you will be added to the waitlist. A physician referral will also be required before scheduling any therapy services. Knowing your availability will help us know to contact you when a session becomes available. Knowing your insurance coverage will help you understand your family cost participation for this therapy. Please provide a front and back copy of all medical insurance cards. Client Name: Client DOB: Name of Parent/Guardian/POA: Phone Number: Availability What days and times of the day would work best for therapy (circle all that apply)? Monday Tuesday Wednesday Thursday Friday 8 10 am 10 noon Noon 2pm 2pm 5pm Please complete all forms and return to: PROVAIL 12550 Aurora Ave North Seattle, WA 98133 206-363-7303 (clinic) 206-826-0181 (fax) I understand and accept my responsibility to pay any remaining balance, including deductible and co payments, required under my insurance plan. Signature Date 1 PROVAIL Therapy Services Application 05 2015 6

Insurance Information: Please phone your Insurance Company and fill out this form the best you can. This is very helpful information if you are unfamiliar with your coverage. Name of your Insurance: Insurance Phone Number: Policy Holder s Name: Effective Date of Policy: ID #: Plan/Group #: When you call be sure to write down the name of the person that you talk to for later reference. Contact Person: Date, Time of call: Say, I m calling to clarify my benefits and coverage for neurodevelopmental outpatient services. If your Insurance provider states you do not have coverage under this benefit ask them to clarify benefits for Speech and/or Occupational Therapy. Other helpful information: PROVAIL Tax ID#: 91 0593488 PROVAIL s National Provider Identification # (NPI): 1477760197 Questions to ask: Is PROVAIL, on the Participating Provider List? Yes No If PROVAIL is NOT in your network, then ask these questions: o Does my policy allow me to choose my own therapist? Yes No o Can I go outside of my network or the provider list? Yes No If yes, what is the difference/cost? Do I need a Letter of Medical Necessity from a Primary Care Doctor to access outpatient neurodevelopmental services or Speech and/or Occupational Therapy? Yes No Is Pre authorization from my insurance company needed for outpatient neurodevelopmental services or Speech and/or Occupational Therapy? Yes No If yes, how is it submitted? Then ask: What is my Co pay % or $ /session. Is the co pay or coinsurance per day or per therapy? (For example, if your child sees an OT and Speech pathologist and you have a $15 copay, do you owe $15 per therapy which totals $30 or only $15 per day? Do I have a deductible? Yes No What is the amount of my Deductible $ / family or individual? 2 PROVAIL Therapy Services Application 05 2015 7

Has my deductible been met for this year? Yes No How much have I paid towards my deductible? What are the dates for my benefit year? to What is my maximum out of pocket expense for the year? What is my benefit maximum? How may visits are allowed per year, per therapy? visits for OT, visits for ST Have any of my benefits been used to date? Yes No If yes, please explain: Are the following CPT codes covered? Therapy Code Yes No Speech Therapy (ST) 92523, 92507, 92508, 92607, 92609, 92608, 97532 Occupational Therapy (OT) 97003, 97004, 97110, 97112, 97542, 97530, 97535, 97760, 97762 Disclaimer: The CPT codes on this form are subject to change based on your needs and services provided. Please ask your therapist if you have questions regarding the codes being used. Please be aware that the information obtained from your insurance company is not a guarantee of coverage/payment. Is there any plan exclusions for Self Care? Yes No If yes, please explain: ADDITIONAL TIPS 1. Keep a paper trail. Always make note of the date whenever you call your insurance, and have paper and pen ready to write down as much information as you can. If possible, get the first and last name of the insurance representative you are speaking with, along with a number/extension where that person can be reached and the name of that person s supervisor. 2. Remember that YOU are the customer! Don t feel rushed when talking to your insurance representative; they are there to serve you. Take your time asking questions and be sure you understand their answers before hanging up. 3. Keep copies of everything! Including copies of referrals from your PCP, copies of specialty evaluations, copies of anything sent to you from your insurance company even if your insurance covers at 100% 4. MONITOR your benefits! If you or your child is receiving ongoing services, call your insurance on a regular basis (ie: once a month) to get an update on the status of your benefits. If your benefits are running out, let your therapist know so options can be discussed. Referrals and authorization must be renewed on a regular basis, if you don t monitor this you may be responsible for the bill. 5. Tell us if your INSURANCE CHANGES!! Let PROVAIL know in advance of your next appointment if your insurance has changed. You will need to complete this worksheet again, and possibly get a new referral and/or authorization. 3 PROVAIL Therapy Services Application 05 2015 8

Therapeutic and Assistive Technology Services LEGAL REPRESENTATION Client Name: Do you (client) have a guardian? No Do you (client) have a financial payee? No Your billing address: Yes Guardian Name: Yes Payee Name: Guardian Address: Payee Address: Guardian Phone: Payee Phone: Guardian Email Payee Email 12550 Aurora Ave. N. Seattle, WA 98133 Phone: 206-363-7301 Fax: 206-826-0181 frontoffice@provail.org PROVAIL Therapy Services Application 05 2015 9