Dermatology Patient Insurance Verification Form

Patient Information

• Full Name: ________________
• Date of Birth: ____________
• Patient ID: _______________
• Contact Phone: ___________
• Email: __________________

Primary Insurance Information

• Insurance Company: _________________
• Policy Number: ____________________
• Group Number: ____________________
• Policy Holder Name: _______________
• Relationship to Patient: ____________
• Policy Holder DOB: _______________

Insurance Verification Checklist

Coverage Verification

• Plan Status (Active/Inactive)
• Effective Date: ____________
• Termination Date: _________
• Deductible Amount: $_______
  • Amount Met: $_______
• Co-payment Amount: $_______
• Co-insurance: ____%

Dermatology-Specific Coverage

• Office Visit Coverage
• Procedure Coverage
  • Biopsies
  • Excisions
  • Laser Treatments
  • Cosmetic Procedures
• Prior Authorization Requirements
• Referral Requirements

Authorization Details

• Prior Auth Required? ☐ Yes ☐ No
• Auth Number: ________________
• Valid Through: ______________

Verification Completed By

• Staff Name: ________________
• Date: _____________________
• Time: _____________________

Note: Verification of benefits is not a guarantee of payment