Patient Information
- Full Name: ____________________
- Date of Birth: ________________
- Insurance ID #: _______________
- Group #: _____________________
- Primary Phone: _______________
Insurance Provider Details
- Insurance Company Name: _______________________
- Claims Address: _____________________________
- Provider Services Phone: _____________________
- Policy Holder Name: ________________________
- Relationship to Patient: _____________________
Benefits Verification
Coverage Information
- Effective Date: ________________
- Plan Year: ____________________
- Deductible Amount: $__________
- Amount Met: $_________________
- Co-payment Amount: $__________
- Co-insurance %: ______________
Chiropractic Benefits
- Number of Visits Allowed Per Year: _______
- Visits Used: _______
- Visits Remaining: _______
- Prior Authorization Required? □ Yes □ No
- Referral Required? □ Yes □ No
Covered Services
- Spinal Manipulation: □ Yes □ No
- X-rays: □ Yes □ No
- Physical Therapy: □ Yes □ No
- Massage Therapy: □ Yes □ No
- Therapeutic Exercises: □ Yes □ No
Verification Details
- Date Verified: ________________
- Time Verified: ________________
- Representative Name: __________
- Reference #: _________________
Staff Use Only
- Verified By: __________________
- Notes: _______________________
This verification is not a guarantee of payment. Benefits are subject to all plan provisions, limitations, and requirements at the time of service.