Nutrition Services Insurance Verification Form

Patient Information

• Full Name: ___________________________
• Date of Birth: ________________________
• Address: _____________________________
• Phone: ______________________________
• Email: _______________________________

Primary Insurance Information

• Insurance Company: ____________________
• Member ID: __________________________
• Group Number: _______________________
• Policy Holder Name: __________________
• Policy Holder DOB: ___________________
• Relationship to Patient: _______________

Medical Nutrition Therapy (MNT) Coverage Verification

• Diabetes Management
• Obesity/Weight Management
• Cardiovascular Disease
• Eating Disorders
• Other: ___________________________

Authorization Details

• Prior Authorization Required? □ Yes □ No
• Authorization Number: _________________
• Number of Visits Approved: ____________
• Coverage Period: _____________________
• Copay Amount: $_____________________
• Deductible: $_______________________
• Deductible Met? □ Yes □ No

Certification

I certify that the information provided above is accurate and complete. I authorize the release of any medical information necessary to process insurance claims.

Signature: _________________________ Date: _____________________________

Office Use Only

• Verification Date: ___________________
• Verified By: _______________________
• Notes: ____________________________