Gastroenterology Patient Insurance Verification Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Address: _________________ City/State/ZIP: _________________
• Phone: _________________ Email: _________________

Primary Insurance

• Insurance Company: _________________
• Policy Number: _________________ Group Number: _________________
• Policy Holder Name: _________________ DOB: _________________
• Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _________________

Secondary Insurance (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): _________________
• Date of Service: _________________

Authorization Requirements

□ Prior Authorization Required □ Referral Required

Authorization Number: _________________ Referral Number: _________________

Insurance Verification (Office Use Only)

• Date Verified: _________________
• Staff Member: _________________
• Deductible: $_________ Amount Met: $_________
• Co-Insurance: % Co-Pay: $
• Out-of-Pocket Maximum: $_________ Amount Met: $_________

Patient Acknowledgment

I hereby confirm that the insurance information provided above is accurate and complete.

Signature: _________________ Date: _________________