Insurance Verification

Thank you for submitting your insurance to our website. We strive to make the process as easy as possible for you and our client’s. You can read more about our commitments and values here – https://nestlife.us/nest-life-identity-and-culture/.

Insurance Verification

Start Client Information
Insurance Information
Read Acknowledgement

Please complete all steps in this multi-step form to verify insurance information for services at Nest Life.
*data is saved as you progress (unless browser cookies/cache are deleted)

CLIENT INFORMATION

Today’s Date

Diagnosis

First Name

Middle Name

Last Name

Sex

DOB

Age

Social Security

Address Line 1

Address Line 2

City

State

Zip Code

Primary Care Physician (PCP)

PARENT(S) INFORMATION

1ST PARENT NAME

First Name

Last Name

Occupation

Employer

Phone/Mobile

Is there a second parent?

Yes

2ND PARENT NAME

First Name

Last Name

Occupation

Employer

Phone/Mobile

Marital Status

INSURANCE INFORMATION

Is this patient covered by insurance?

Yes

PERSON RESPONSIBLE FOR BILL

First Name

Last Name

Address (if different from client)

Address Line 1

Address Line 2

City

State

Zip Code

Employer

Occupation

Employer Phone

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

INSURANCE PROVIDER

Primary Insurance

Insurance Phone #

Coverage Effective Date

Group #

Policy #

Co-payment

Subscriber’s Name

Social Security

Birth Date

Relationship to Client

Relationship Other

Do you have secondary insurancer?

Yes

Secondary Insurance

Insurance Phone #

Coverage Effective Date

Group #

Policy #

Co-payment

Subscriber’s Name

Social Security

Birth Date

Relationship to Client

Relationship Other

Agreement

This information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Nest Life, Inc. or insurance company to release any information required to process my claims.

We will submit your claims, however we must emphasize that as health care providers, our relationship is with you, not your insurance company. Although we attempt to verify your ABA/Autism benefits with your insurance policy, please be advised this is only an estimate of your coverage based on the information given to us at the time of inquiry.

By signing below, you confirm that you understand:

It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified prior to your appointment.

If your insurance policy requires a prescription from your primary care physician, it is your responsibility to have that faxed to our office prior to your appointment.
Not all services are a covered benefit with all insurance plans.
It is your responsibility to be aware of what service(s) is being provided to you and if it is not a covered benefit under your insurance policy.
You are responsible for any non-covered charges not payable by your insurance policy.
Although filing your insurance claims is a courtesy extended to you, all charges are always your responsibility from the date services are rendered.

We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we urge you to contact us promptly for assistance in the management of your account. If you have any questions or concerns about the information, please do not hesitate to ask us. We are here to help you.

Parent/Guardian Signature (please enter full name)

Date / Time

Insurance Verification

CLIENT INFORMATION

PARENT(S) INFORMATION

INSURANCE INFORMATION

Locations

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