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: ⬚ Self ⬚ Spouse ⬚ Parent ⬚ Other
- Policy Holder DOB: //___ SSN: -____-
Secondary Insurance Information (if applicable)
- Insurance Company: _______________________________________
- Policy Number: _________________ Group Number: ____________
- Policy Holder Name: ______________________________________
Surgical Procedure Information
- Planned Procedure: _______________________________________
- CPT Code(s): ___________________________________________
- ICD-10 Code(s): ________________________________________
- Scheduled Date: //___
Authorization Information
- Prior Authorization Required? ⬚ Yes ⬚ No
- Authorization Number: ____________________________________
- Date Obtained: //___ Valid Through: //___
Patient Financial Responsibility
- Estimated Deductible: $_________ Amount Met: $_________
- Co-Insurance: % Co-Payment: $
- Out-of-Pocket Maximum: $_________ Amount Met: $_________
Verification Details
- Date Verified: //___
- Verified By: ____________________________________________
- Reference Number: ______________________________________
Authorization
I hereby authorize the release of any medical information necessary to process insurance claims related to my surgical care. I authorize payment of medical benefits directly to the physician/facility for services rendered.
Patient/Guardian Signature: _________________ Date: //___