Select the treatment plan, then fill in the information below based on eligibility reports and/or calls to provider services of the patient's insurance.

Things to keep in mind:

• Eligibility reports from Experian, Availity or anywhere else are not a good resource for understanding treatment costs. Use them as a reference and for costs for office visits only. ALWAYS CALL THE PLAN.
• Co-insurance and Co-pay are not the same thing. Co-pays are flat fees. Co-insurance adjusts based on the insurance allowed amount and how much of the deductible has been met.
• If the patient responsibility for a code is listed as a percentage, it means it is A: subject to the deductible, and B: calculated as a percentage of the insurance allowed amount.
• Just because one code is a copay does not mean that every code is a copay. Often, you will see a co-pay for evaluations and follow-ups, but co-insurance for the actual treatments.
• This form does not take into account the Spravato Savings Plan.