Patient Information
- Full Name: _________________ Date of Birth: _________________
- Social Security Number: _________________
- Primary Phone: _________________ Secondary Phone: _________________
- Email Address: _________________
- Home Address: _________________
Primary Insurance Information
- Insurance Company Name: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________
- Policy Holder DOB: _________________
- Relationship to Patient: _________________
- Prior Authorization Required? □ Yes □ No
Secondary Insurance Information (if applicable)
- Insurance Company Name: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________
- Policy Holder DOB: _________________
Cardiac-Specific Coverage Verification
- Cardiac Diagnostic Tests Coverage: □ Yes □ No
- Nuclear Studies Coverage: □ Yes □ No
- Echocardiogram Coverage: □ Yes □ No
- Stress Test Coverage: □ Yes □ No
- Cardiac Device Coverage: □ Yes □ No
Authorization Information
- Referring Physician: _________________
- NPI Number: _________________
- Diagnosis Code(s): _________________
- Authorization Number: _________________
- Date Range: _________________ to _________________
Patient Acknowledgment
I hereby authorize the release of any medical information necessary to process insurance claims and request payment of benefits to the physician or supplier for services provided.
Signature: _________________ Date: _________________
For Office Use Only
- Verified By: _________________ Date: _________________
- Copay Amount: $_________________
- Deductible Amount: $_________________
- Coinsurance: _________________%
- Out-of-Pocket Maximum: $_________________