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: _________________
Workers' Compensation Information (if applicable)
- Claim Number: _________________ Date of Injury: _________________
- Employer Name: _________________ Contact: _________________
- Adjuster Name: _________________ Phone: _________________
Authorization Requirements
- □ Prior Authorization Required
- □ Referral Required
- Authorization Number: _________________
- Number of Visits Approved: _________________
- Valid From: _________________ To: _________________
Benefits Verification (Staff Use Only)
- Deductible: $________ Amount Met: $________
- Co-Insurance: % Co-Pay: $
- Visit Limit per Year: ________ Visits Used: ________
- Out-of-Pocket Maximum: $________ Amount Met: $________
Staff Verification
- Verified By: _________________ Date: _________________
- Time: _________________ Reference #: _________________
Note: This form must be completed and verified prior to initial visit