Patient Information
- Full Name: _________________ Date of Birth: _________________
- Address: _________________ City/State/ZIP: _________________
- Phone: _________________ Email: _________________
Primary Insurance Information
- Insurance Company Name: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _________________
Secondary Insurance Information (if applicable)
- Insurance Company Name: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _________________
Neurological Service Coverage Verification
- Prior Authorization Required? □ Yes □ No
- Referral Required? □ Yes □ No
- Deductible Amount: $________ Amount Met: $________
- Co-payment Amount: $________
- Coverage for:
- Diagnostic Testing □ Yes □ No
- EEG Studies □ Yes □ No
- EMG/NCV Studies □ Yes □ No
- Neuroimaging □ Yes □ No
Authorization
I hereby authorize [Practice Name] to verify my insurance benefits and submit claims on my behalf. I understand that I am responsible for any charges not covered by my insurance.
Signature: _________________ Date: _________________
For Office Use Only
- Verification Date: _________________ Time: _________________
- Verified By: _________________ Reference #: _________________
- Notes: _________________________________________________