**** PLEASE TYPE FORM AND FAX TO (510) 777-2225 ****

Complete this form at intake/registration and Fax it to ACBHCS Provider Relations Billing Unit as soon as insurance is verified. For questions regarding completion of this form, please call (800) 878-1313.

Date:	/ /	Completed by:
Organization:	John George Pavilion	Phone:	( ) -
RU #:	Organization FAX #:	( ) -

Client Name:	Sex:
LAST	FIRST	M.I.

Date of Birth:	/ /	InSyst Client #	SSN	- -

Insurance

HPAC:
HPAC MCE
HPAC HCCI
HPAC County

HPAC Policy Number:	Effective Date:	/ /

Private Insurance:

Insured Name:
LAST	FIRST	M.I.

Policy Number	Effective Date:	/ /
Group Number	Expiration Date:	/ /

Insurance Company Name:

Billing Address:
City:	State:	Zip Code:	-

Phone:	( ) -	Fax:	( ) -

BENEFITS VERIFIED WITH:

Insurance Contact Name:	Phone:	( ) -
UMDAP Liability:	Eff. Date:	/ /	Exp. Date	/ /

AUTHORIZATION VERIFIED WITH:

Ins. Contact Name:	Phone:	( ) -
Authorization Number:
Effective Date:	/ /	Expiration Date:	/ /

Medicare

Medicare ID #:	Pt A Eff. Date:	/ /	Pt B Eff. Date:	/ /

Comments:

For ACBHCS Use Only	Date Received ______________

InSyst Ins Policy entered by ____________________________ Date ___________________
InSyst Medicare Policy entered by ________________________ Date ___________________

John George Pavilion

MHS Medicare/Insurance Plan

Verification and Authorization Form

This document may contain protected health information only for use by the intended recipients. Any use, distribution, copying or disclosure by any persons other than the intended recipient is strictly prohibited and may be subject to civil action and/or criminal penalties. If you have received this document in error, please immediately notify ACBHCS at (800) 878-1313.

G:\Gross Claiming\InSurance Billing\JGP Insurance Plan Verification and Insurance Authorization Worksheet 11_08_12.dot

Insurance Plan Verification and Insurance Authorization Worksheet

martinjos

2012-11-09

BHCS