Concierge Medicine Insurance Verification Form

Patient Information

• Full Name: ________________
• Date of Birth: ____________
• Member ID: _______________

Primary Insurance Information

• Insurance Company: ________________
• Plan Type: ____________________
• Policy Number: ________________
• Group Number: ________________
• Policy Holder Name: ________________
• Policy Holder DOB: ________________
• Relationship to Patient: ________________

Secondary Insurance Information (if applicable)

• Insurance Company: ________________
• Plan Type: ____________________
• Policy Number: ________________
• Group Number: ________________
• Policy Holder Name: ________________
• Policy Holder DOB: ________________
• Relationship to Patient: ________________

Concierge Program Details

• Annual Membership Fee: $________
• Membership Start Date: ________
• Membership Renewal Date: ________

Insurance Verification (Office Use Only)

• Date Verified: ________________
• Verified By: ________________
• Effective Date: ________________
• Deductible: $________________
• Coinsurance: ________________%
• Copay Amount: $________________
• Out-of-Network Benefits: □ Yes □ No

Authorization

I hereby authorize [Practice Name] to verify my insurance benefits and submit claims on my behalf. I understand that while my concierge membership fee is separate from insurance billing, the practice will continue to bill my insurance for covered medical services.

Signature: ________________ Date: ________________

Notes