Patient Insurance Verification Form

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Address: ________________________________________________
• Phone: (__) - Email: _________________________

Primary Insurance

• Insurance Company: _______________________________________
• Policy Number: _________________ Group Number: ____________
• Policy Holder Name: ______________________________________
• Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _____
• Policy Holder DOB: //___ SSN: -____-

Secondary Insurance (if applicable)

• Insurance Company: _______________________________________
• Policy Number: _________________ Group Number: ____________
• Policy Holder Name: ______________________________________
• Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _____

Insurance Verification (Office Use Only)

• Date Verified: //___
• Staff Initial: _____
• Copay Amount: $______
• Deductible: $______ Amount Met: $______
• Coinsurance: ______%
• Prior Authorization Required? □ Yes □ No
• Referral Required? □ Yes □ No

Attestation

I hereby authorize [Practice Name] to verify my insurance coverage and benefits. I understand that I am responsible for any charges not covered by my insurance.

Signature: _________________________ Date: //___