Verification of Benefits Form - Leaps and Bounds Pediatric Therapy

Verification of Benefits

Verification of Benefits (VoB)

The following is information required for LEAPS AND BOUNDS THERAPY to bill your insurance. This information is required before services can begin. The information obtained by Leaps and Bounds Therapy from your insurance plan is not a guarantee of payment and all services are subject to the terms and agreement of your plan, at the time services are rendered. Any pre-certifications will be initiated by Leaps and Bounds Therapy. We strongly recommend calling your insurance plan with any questions you may have. PATIENT RESPONSIBLE FOR ALL DEDUCTIBLE AND OUT-OF-POCKET EXPENSES AS DETERMINED BY PLAN .

INFORMATION OBTAINED ON THIS FORM BY LEAPS AND BOUNDS THERAPY AND ABILLINGCO IS NOT A GUARANTEE OF COVERAGE. YOUR PROVIDER, IS NOT RESPONSIBLE FOR DEVIATIONS FROM THE INSURANCE COVERAGE PROVIDED BY YOUR INSURANCE COMPANY FOR CLARIFICATION ON PLAN LIMITATIONS. IT IS HIGHLY SUGGESTED FOR YOU TO CALL AND LEARN YOUR PLANS COVERAGE

Client information

Client's Name(Required)

First Last

Client's date of birth(Required)

Client's address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home phone(Required)

Mobile phone(Required)

Primary email for correspondence(Required)

Primary Caregivers Name(Required)

First Last

Primary insurance information

Subscriber's Name(Required)

First Last

Subscriber's date of birth(Required)

Subscriber's Employer(Required)

Client's relationship to subscriber(Required)

Subscriber ID(Required)

Primary Insurance(Required)

Plan Name(Required)

Group Number(Required)

Effective Date(Required)

Plan exemptions and other notes