MOSAIC UNLIMITED, INC.
9 JUNCTION DRIVE WEST, SUITE 3, GLEN CARBON, IL 62034
Payment/Insurance Verification Form (Page 1 of 2)
Choosing to bill for counseling sessions through your insurance carrier is an important decision you must
make. According to federal regulations, you may choose to ‘opt’, pay out-of-pocket, and NOT bill through
your insurance policy. Clients who ‘opt’ are private pay clients. Should this be your preference, Mosaic
Unlimited, Inc. would NOT have the authorization to share your records with your insurance
company. The decision made at the outset of services regarding payment of services is changeable at any
time by completing a new form and updating your file. However, the fee or payment option is not retroactive
and only changes for subsequent sessions.
Here is an example. Let’s say you opt to be a “private pay client” in January, and pay for services at $145.00 per session
for 4 weeks. You cannot change your status from private pay client to Insurance Client for those January dates of
service. If you decide to bill insurance for your February sessions, you would need to complete a new form expressing
that preference, and your rates would reflect that change for your February sessions and all subsequent sessions as long
as that is your expressed preference. Keep in mind if you choose to use insurance benefits, the insurance company will
have instant access to your records. In addition, you will be responsible for deductibles and co-pays for subsequent
sessions.
Knowing your out-of-pocket expenses prior to receiving services is your right and your responsibility.
Select a box:

I choose to be designated as a private pay client at Mosaic Unlimited, Inc.. I will pay for sessions
out-of pocket with cash, check, or credit card, in accordance with my signed contract for services. I do not
authorize Mosaic Unlimited, Inc., its agents or employees, to share my private information with my insurance
company.

I choose to bill my insurance company for mental health services. I understand that if Mosaic
Unlimited, Inc. is in-network with my carrier, my rates may be discounted in accordance with their business
contract. I understand that if Mosaic Unlimited, Inc. is out of network with my insurance company, I am
responsible for co-pays, deductible payments, or any portion of the session fees not covered by my plan. I
grant this permission to be effective as of the date of my signature and witnessed by a representative of
Mosaic Unlimited, Inc.
INITIAL ____ I understand that Mosaic Unlimited and my insurance company can terminate network
contracts at any time and neither is required by law to inform me of this change. However, Mosaic Unlimited
will make every effort to communicate any contractual change via letter, telephone call or in person. This
change will affect my financial responsibility for subsequent sessions.
I authorize the release or exchange of information from Mosaic Unlimited, Inc. to my insurance company,
EAP, managed care group, and/or other paying organization to facilitate payment and continued coverage
under the mental health benefit of my policy. I consent to have Mosaic Unlimited, Inc. submit claims on my
behalf to my insurance company, EAP, managed care group, or other paying organization and receive
payment according to the guidelines of my policy. I understand that I am responsible for payment for services
rendered by Mosaic Unlimited, Inc. regardless of reimbursement for these services by the insurance company
and that any inaccuracy in information on this form may result in nonpayment by my insurance company. I
agree to notify Mosaic Unlimited, Inc. as soon as I am aware of any changes in my health condition or health
plan coverage.
___________________________________________________________
Client or Parent/Guardian SIGNATURE
_______________________
DATE
___________________________________________________________
Mosaic Unlimited, Inc. EMPLOYEE/AGENT
______________________
DATE
***Back of page is a list of questions to verify your mental health benefits with insurance.
Phone: 618.407.0900
Fax: 618.205.3561
www.metrostltherapy.com
MOSAIC UNLIMITED, INC.
9 JUNCTION DRIVE WEST, SUITE 3, GLEN CARBON, IL 62034
Payment/Insurance Verification Form (Page 1 of 2)
PROVIDER INFORMATION: Renee Keller, LCSW at Mosaic Unlimited
Mosaic NPI: 1124379755 Renee Keller NPI: 1487841714
Primary Mental Health Insurance: ________________ Telephone #: _______________________
Date Contacted: ______________________ Representative’s Name:______________________
Deductible for
Individual Sessions:
Annual effective date
and amount:
Deductible amount met
as of today:
Deductible for Couples
or Family Sessions:
Annual effective date
and amount:
Deductible amount met
as of today:
Are the following
mental health services
covered:
In-Network Providers
Individual Session: Yes/No
Out-of-Network Providers
Individual Session: Yes/No
Date:_________________
$____________________
Date:_________________
$____________________
$____________________
$____________________
Couples or Family Sessions:
Yes/No
Couples or Family Sessions:
Yes/No
Date:_________________
$____________________
Date:_________________
$____________________
$____________________
$____________________
45 Min (90834)
55 Min (90837)
Group (90853)
Complexity (90785)
Yes/No
(Write below if coverage differs
for out-of-network)
__________________________
__________________________
__________________________
Yes/No
Co-pay $________ or %______
Co-pay $________ or %______
Yes/No
If yes, number of visits used
this year ________
Yes/No
If yes, number of visits used this
year ________
Yes/No
Yes/No
Yes/No
Yes/No
Is pre-authorization
required?
What is the co-pay or
percentage I am
responsible to pay?
Is there a limit on
number of visits per
year?
Do you have a ‘Health Savings Account?’ Yes/No
*Important question to ask your insurance representative for out-of-network reimbursement:
“What is the process to get reimbursed for out-of-network services?”
Each insurance company has a different reimbursement process. Ask your insurance carrier’s
reimbursement requirements and copies of the necessary forms.
Verifying benefits does not guarantee payment for services.
Phone: 618.407.0900
Fax: 618.205.3561
www.metrostltherapy.com