COMMERCIAL ELIGIBILITY FORM

BC/BS ____ Harvard Pilgrim ____ Tufts ____ UBH ____ *Other ____

Client:___________________ Date:______________	Inpatient: ________ Outpatient: ____________
Patient: _____________________________________	Policy #: ________________________________
Listed on Policy: _____________________________	*Insurance Co.: ____________________________
Type of Policy: Indiv. _________________________ Family________________________	Copay: _________________________________
Deductible: Indiv. ____________ Met? ___________ Family___________ Met? ___________ None _____________	Subscriber: ______________________________ Policy Effective Date:______________________
Therapist Restrictions? ________________________ ___________________________________________	Visits/year: ______________________________ Visits Auth: ______________________________ Authorization #: __________________________ Date Range: _____________________________ Treatment Plan: ___________________________
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Date Received: _____________Confirmed: ________	Contact: ____________________________
Eligibility Done By: _________________________	Tel #: ____________________________
	Faxed Back: YES ________ NO ________ Called Back: YES ________ NO ________ Yellow Mailed: YES _______ NO ________