**** 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. Forms are located at www.acbhcs.org/providers.

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

Client Name:	Sex:
LAST	FIRST	M.I.

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

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:	( ) -

AUTHORIZATION VERIFIED WITH:

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

Medicare

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

ERMHS Clients

For ERMHS clients (formerly AB3632), is there parental consent to bill OHC? (attach documentation)
YES
NO

Comments:

For ACBHCS Use Only	Date Received ______________
InSyst Ins Policy entered by _________________________ Date ___________________
InSyst Medicare Policy entered by ________________________ Date ___________________

MHS 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\MHS Insurance Plan Verification and Authorization Form rev 12_16_11.doc

Insurance Plan Verification and Insurance Authorization Worksheet

Sphere

2012-05-14

martinjos

BHCS