Patient Information
- Full Name: _________________ Date of Birth: _________________
- Address: _________________ Phone: _________________
- Email: _________________ SSN: _________________
Primary Insurance Information
- Insurance Company: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _________________
Secondary Insurance Information (if applicable)
- Insurance Company: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _________________
Procedure Information
- Scheduled Procedure: _________________
- CPT Code(s): _________________
- ICD-10 Code(s): _________________
- Scheduled Date: _________________
Pre-Authorization
- Pre-authorization Required? □ Yes □ No
- Pre-authorization Number: _________________
- Date Obtained: _________________
- Authorization Valid Until: _________________
Insurance Verification (Office Use Only)
- Date Verified: _________________
- Verified By: _________________
- Deductible Amount: $________ Amount Met: $________
- Co-Insurance: ________%
- Co-Pay Amount: $________
- Out-of-Pocket Maximum: $________ Amount Met: $________
Patient Authorization
I authorize the release of any medical information necessary to process insurance claims. I authorize payment of medical benefits to the physician for services rendered.
Signature: _________________ Date: _________________