Endocrinology Patient Insurance Verification Form

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Address: ________________________________________________
• Phone: (__) - Email: _________________________

Primary Insurance Information

• Insurance Company: ______________________________________
• Policy Number: ________________________________________
• Group Number: ________________________________________
• Policy Holder Name: ___________________________________
• Relationship to Patient: ________________________________
• Policy Holder DOB: //___

Secondary Insurance Information (if applicable)

• Insurance Company: ______________________________________
• Policy Number: ________________________________________
• Group Number: ________________________________________
• Policy Holder Name: ___________________________________

Endocrine-Specific Coverage Verification

• Diabetes Supplies Coverage
• Continuous Glucose Monitor Coverage
• Insulin Pump Coverage
• Hormone Therapy Coverage
• Thyroid Medication Coverage

Prior Authorization Requirements

• Endocrine Procedures: [ ] Yes [ ] No
• Specialty Medications: [ ] Yes [ ] No
• Laboratory Tests: [ ] Yes [ ] No

Patient Financial Responsibility

• Annual Deductible: $_________ Amount Met: $_________
• Co-Insurance: __________%
• Specialist Visit Co-Pay: $_________

Authorization

I hereby authorize the release of any medical information necessary to process insurance claims and request payment of benefits to the physician rendering services.

Signature: _____________________ Date: //___

Office Use Only

• Verification Date: //___
• Staff Member: _________________
• Coverage Effective Date: //___
• Coverage End Date: //___