Geriatric Patient Insurance Verification Form

Patient Information

• Full Name: _________________________ Date of Birth: //____
• Social Security Number: --___
• Medicare Number: ________________

Primary Insurance

• Insurance Company: _________________
• Policy Number: ____________________
• Group Number: ____________________
• Effective Date: //____
• Plan Type: □ Medicare □ Medicare Advantage □ Supplemental □ Other

Secondary Insurance

• Insurance Company: _________________
• Policy Number: ____________________
• Group Number: ____________________
• Effective Date: //____

Long-Term Care Insurance

• Provider: _________________________
• Policy Number: ____________________
• Daily Benefit Amount: $_____________
• Elimination Period: ________________

Medicare Part D (Prescription Drug Coverage)

• Plan Provider: _____________________
• ID Number: _______________________
• BIN: _________ PCN: _____________

Authorization

I hereby authorize the verification of my insurance benefits and understand that this does not guarantee payment for services rendered.

Signature: _________________________ Date: //____

Office Use Only

• Verified By: ______________________
• Date Verified: //____
• Copay Amount: $__________________
• Deductible Remaining: $___________
• Pre-authorization Required? □ Yes □ No
• Next Eligibility Review Date: //____