Patient Information
- Full Name: _________________________ Date of Birth: //____
- Medical Record #: ___________________ Social Security #: --___
- Primary Address: ________________________________________________
Primary Insurance Information
- Insurance Company Name: ________________________________________
- Policy ID #: ____________________ Group #: ______________________
- Policy Holder Name: ____________________________________________
- Relationship to Patient: ☐ Parent ☐ Guardian ☐ Other: ____________
- Policy Holder DOB: //____ SSN: --___
- Employer: ____________________________________________________
Secondary Insurance Information (if applicable)
- Insurance Company Name: ________________________________________
- Policy ID #: ____________________ Group #: ______________________
- Policy Holder Name: ____________________________________________
- Relationship to Patient: ☐ Parent ☐ Guardian ☐ Other: ____________
Authorization
- Prior Authorization Required? ☐ Yes ☐ No
- Referral Required? ☐ Yes ☐ No
- Co-pay Amount: $_______
- Deductible: $_______ Amount Met: $_______
Verification Details
- Date Verified: //____
- Staff Member: ________________________________________________
- Insurance Rep Name: __________________________________________
- Reference #: ________________________________________________
Coverage Information
- Well Child Visits: ☐ Covered ☐ Not Covered
- Immunizations: ☐ Covered ☐ Not Covered
- Specialist Referrals: ☐ Covered ☐ Not Covered
- Lab Work: ☐ Covered ☐ Not Covered
Additional Notes
This information is valid as of verification date and subject to change