Patient Insurance Verification Form - Internal Medicine

Patient Information

• Date of Verification: //____
• Patient Name: ________________________
• DOB: //____
• Insurance ID#: ________________________
• Group#: ________________________

Primary Insurance Details

• Insurance Company: ________________________
• Effective Date: //____
• Plan Type: □ HMO □ PPO □ EPO □ Other: ________
• Insurance Phone#: ________________________
• Reference/Verification#: ________________________

Benefits Verification

Office Visit Coverage

• Deductible: $________ □ Met □ Unmet
• Amount Met: $________
• Copay Amount: $________
• Coinsurance: ________%
• Out-of-Pocket Maximum: $________

Preventive Care

• Annual Physical: □ Covered □ Not Covered
• Immunizations: □ Covered □ Not Covered
• Lab Work: □ Covered □ Not Covered

Authorization Requirements

• PCP Referral Required: □ Yes □ No
• Prior Authorization Required for: □ Procedures □ Diagnostic Testing □ Specialist Referrals □ Other: ________________________

Additional Notes

Verification Completed By

• Staff Name: ________________________
• Date: //____
• Time: : □ AM □ PM