Patient Information
- Full Name: _________________ Date of Birth: _________________
- SSN: _________________ Medical Record #: _________________
- Primary Phone: _________________ Secondary Phone: _________________
- Address: ________________________________________________
Insurance Information
Primary Insurance
- Insurance Company: _________________
- Policy #: _________________ Group #: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: _________________
- Prior Authorization Required? □ Yes □ No
Secondary Insurance (if applicable)
- Insurance Company: _________________
- Policy #: _________________ Group #: _________________
- Policy Holder Name: _________________ DOB: _________________
Treatment Verification
Diagnosis Information
- Primary Diagnosis (ICD-10): _________________
- Secondary Diagnosis: _________________
- Stage: _________________ Date of Diagnosis: _________________
Treatment Plan Verification
- Chemotherapy Drugs: _________________
- Treatment Frequency: _________________
- Expected Duration: _________________
- Clinical Trial? □ Yes □ No
Coverage Verification
- Deductible Amount: $_________ Amount Met: $_________
- Out-of-Pocket Maximum: $_________ Amount Met: $_________
- Co-Pay Amount: $_________ Co-Insurance: _________%
- Lifetime Maximum: $_________
Authorization Details
- Prior Authorization #: _________________
- Date Obtained: _________________ Valid Through: _________________
- Number of Treatments Approved: _________________
Verification Completed By
- Staff Member Name: _________________
- Date: _________________ Time: _________________
- Reference #: _________________
Note: This verification is valid for 30 days from the date of completion.