Inquiry / Benefits Verification Form

 

Inquiry Date:

 

Client Information:

Name:

Date of Birth:

Street Address:

City, State, Zip Code:

Phone Number:

 

Referral Source Information:

Name:

Phone Number:

Relationship to Client:

 

Caller Information:

Name:

Phone Number:

Relationship to Client:

 

Insurance Information:

Company Name:

Type:

ID #:

Group #:

Benefit Phone Number:

If different than the Client, Policy Holder’s Name:

      Street Address:

      City, State, Zip Code:

 

 

History

 

Drug Use History:

Chemicals Used:

Amounts/Frequency/Route:

How long/Last Use:

Withdrawal/Seizure Hx:

 

        

Treatment History:

Type/When/Where:

List Treatment Episodes within the calendar year:

 

If currently in Tx, the current LOC:

     Number of days at this LOC:

 

Psych History:

Diagnoses:

Psych Treatments (Type/When/Where):

Suicide Attempts:

Current Medications:

 

Medical Problems:       

Include infectious diseases, open wounds, untreated issues, etc.:

 

 

Problem Areas:

Work/School/Legal/Relationships/Social:

 

 

 

 

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