Client Notice of Benefit Verification
$15.00
End benefit verification headaches!
Don’t spend hours on hold. Conduct an electronic benefits inquiry, then use this form to communicate to your client what you will be collecting each visit until claims are processed.
The form serves several purposes:
- Written documentation to the client of benefit verification results, and what you will collect.
- An explanation of your practice’s policy of non-interference in benefit disputes between the client and the insurance payer.
- Promotes an open discussion of benefits and finances with clients who use insurance benefits, and then acts as a means of documentation of this discussion.
Version update: 01/24/25, to fix formatting errors.
The “Notice of Benefit Verification and Financial Responsibility” is a fillable PDF form with space for electronic signatures. Feel free to modify it to your liking. Integrate it with your existing financial policy, or put it in your forms library on your EMR for new clients to sign at intake!
The first part is a notice that you’ve verified the benefits for a specific policy – with a place to list the policy ID #. You can indicate exactly how much you’ll be collecting each session until claims finalize. There are separate sections for copayment, coinsurance %, and deductible. This will help avoid any allegations of “surprise billing.” And it describes how you’ll adjust balances after claims are processed, if your estimate was off.
The second part is a brief explanation of the limitations of benefit verification, and suggestions for how the client can obtain their full certificate of coverage.
Finally, there’s a place for the client to sign indicating their understanding that benefits are the sole determination of their insurance payer, and that if they have a dispute over a paid/deductible claim, it’s their responsibility to address their dissatisfaction directly with the insurer.
An attestation on the part of the client that they’ve disclosed ALL policies that cover them has been added as well, to mitigate the risk posed by double coverage and lack of Coordination of Benefits.
The purchaser understands that this form has not been legally vetted and that review of participating-provider contracts is highly recommended before implementing this form. No representations are made that this form will comply with all legal jurisdictions, all insurance contracts, and/or all types of policies.Â