Out of Network Benefits Form Jesica Lang, LMFT lic #87402 415-496-6792
Instructions: This is a worksheet to help you determine if your insurance will reimburse you for seeing a therapist who is out-of-network.
1) Check the back of your card and call your insurance company. Here are some questions you can ask your provider:
A) Do I have out-of-network mental health coverage?:___________________________________ B) Do my benefits cover services provided by a Marriage ad Family Therapist?:
_____________________________________________________________________________________ C) Do my benefits cover online therapy?_______________________________________________
D) How many sessions are covered and what is the coverage amount?:___________________ ____________________________________________________________________________________
E) How much will I be reimbursed for a session that costs $175?:_________________________ F) What is my deductible?:___________________________________________________________ G) Have I met my deductible for this year, and if not, how much do I have to spend before I
meet my deductible?:________________________________________________________________ ____________________________________________________________________________________ H) Can I pay for my office visits with my HSA/FSA?:____________________________________
I) Are there any other restrictions I should be aware of?:________________________________ _____________________________________________________________________________________
2) Find your insurance card and fill out the Patient Information here:
A) Name of Patient:__________________________________________________________________ B) Named of Insured (if not Patient):___________________________________________________ C) Patient/Insured Address: __________________________________________________________ D) Patient Date of Birth:______________________________________________________________ E) Insurance Company Name/Phone Number:__________________________________________ F) Subscriber ID#:___________________________________________________________________
3) Bring this sheet to our first session, email it to me using your encrypted email, or you can call me to relay the information to me, then bring it to a session.