Patient Information
- Full Name: ________________________
- Date of Birth: //___
- Insurance ID: ____________________
- SSN (last 4): XXX-XX-_____
Primary Insurance Details
- Insurance Company: ________________
- Policy Number: ___________________
- Group Number: ___________________
- Policy Holder Name: ______________
- Relationship to Patient: ___________
Procedure Information
- Planned Procedure: _______________
- CPT Code(s): ____________________
- ICD-10 Code(s): _________________
- Scheduled Date: //___
Pre-Authorization
- Pre-Authorization Required? □ Yes □ No
- Pre-Auth Number: ________________
- Date Obtained: //___
- Valid Through: //___
Coverage Verification
In-Network Benefits
- Deductible: $________
- Amount Met: $________
- Co-Insurance: ________%
- Co-Pay Amount: $________
- Out-of-Pocket Maximum: $________
Specific Coverage Details
- Facility Coverage: □ Yes □ No
- Assistant Surgeon: □ Yes □ No
- Neuromonitoring: □ Yes □ No
- Hardware/Implants: □ Yes □ No
Verification Details
- Date Verified: //___
- Verified By: ____________________
- Reference Number: ______________
- Insurance Rep Name: ____________
Additional Notes
Staff Certification
I certify that I have verified all insurance information above.
Signature: _________________________
Date: //___