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Contents |
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1. Current Version
Version 4 (Blue/Gray, released Dec 2021) is the current version of our intake form. We may issue further updates periodically, and retire legacy versions. We have historically allowed clients to use legacy versions of our forms. However, we are phasing out legacy forms to prevent certain workflow and coding issues. Do not send benefit requests using legacy forms.
Past Versions
- Version 3 (Teal/Gray). Released Nov 2017.
- Version 2 (Black/White). Released Jan 2015.
- Version 1 (Black/White). Released 2010.
2. Specifications
Tech Specs
Our forms must be filled using the Adobe desktop app. The free version, Adobe Acrobat Reader DC, is sufficient. Set the Adobe desktop app as the default PDF viewer on your system.
Using any other PDF viewer will permanent corrupt the form, creating administrative work and tech issues for our team. Avoid the following:
- Adobe's browser extension. When installing the Adobe desktop app, do not install the browser extension.
- Built-in browser extensions. Some web browsers, including Microsoft Edge, include a built-in PDF viewer. Your OS may prompt you to set a default PDF viewer other than the Adobe desktop app. Disregard these prompts.
- Any other PDF viewer. Other PDF viewers, such as Preview, PDF Expert, and Canva all corrupt our forms.
- Smart phones and tablets. Devices use different software than the Adobe desktop app, so they are incompatible with our system.
Preparation
At minimum, fill in gray fields marked with an asterisk to ensure that we can satisfy the HIPAA verification process.
3. Provider Type Configurations
Our intake form can be configured for Behavioral Health and Acupuncture providers. The major difference between these configurations is the benefit table:
Behavioral Health Configuration
The Benefit Table documents two benefit categories: Mental Health and Substance Use Disorder.
Acupuncture Configuration
The Benefit Table documents three benefit categories: Acupuncture, (Professional or Specialist) Office Visit, and PMR (i.e. Physical Therapy).
4. Sections
Our intake form has ten (10) sections. Each section is detailed in order below.
Top
- Clinic Info
- Disclaimer
Administrative Info
- Date
- Treating for pain/nausea?
- Patient #
- Network participation indicator
Patient Demographics
- Patient Name
- DOB
- Full Address
- Sex
- Insurance ID
- Group
- Rel to Ins
- Carrier
- COB
- Carrier #
- Claims to
- Payer ID
- Insured Details
Policy Information
- Type
- Name
- Policy Term
- Eff Date
- Deductible/OOP Relationship Indicator
- OOP Max Application Indicator
- Deductible
- OOP Max
Benefit Table
- Category
- Coverage
- Copay/Coinsurance
- Max
- Used
- Shared?
- Deductible
- Rx|Auth
Notes
In this section, we will detail any pertinent additional information, including but not limited to:
- Authorization instructions
- Diagnosis restrictions / exclusions
- Contact information
MVA/WC
- Claim Number
- Date of Injury
- Adjuster
- Adjuster #
- Extension
- Claim Open?
- Acu considered?
- Fax #
- Complaint/Dx
- Carrier
Instructions
To request benefit verification, submit this intake to [email protected]. Do not send via Adobe Cloud. Do not provide this form to your patients.
- Sending our intake via Adobe Cloud uses Adobe's servers to transmit PHI, and may constitute a HIPAA violation.
- Patients are unlikely to observe our Specs (above), and thus corrupt our form. They may also give out our form, thereby distributing our intellectual property. Our forms are for your use only.
Documentation
- Rep
- Ref #
- Trans ID
