Patient Information
- Full Name: _________________ Date of Birth: _________________
- Address: _________________ Phone: _________________
- Email: _________________ SSN (last 4): _________________
Primary Insurance Information
- Insurance Company: _________________
- Member ID: _________________ Group #: _________________
- Policy Holder Name: _________________
- Policy Holder DOB: _________________
- Relationship to Patient: _________________
Benefits Verification (Staff Use Only)
Physical Therapy Benefits
- Effective Date: _________________ Plan Year: _________________
- Deductible: $________ Met to Date: $________
- Co-Insurance: % Co-Pay: $
- Visit Limit per Year: _______ Visits Used: _______
- Prior Authorization Required? □ Yes □ No
- Auth #: _________________ Valid Through: _________________
Network Status
- In-Network Provider: □ Yes □ No
- Out-of-Network Benefits Available: □ Yes □ No
Additional Information
- Medicare Cap Applies? □ Yes □ No
- Secondary Insurance? □ Yes □ No
- Workers Comp Case? □ Yes □ No
Verification Details
- Date Verified: _________________ Time: _________________
- Verified By: _________________ Reference #: _________________
- Insurance Rep Name: _________________
Notes
Staff Certification
I certify that I have verified the above information with the insurance carrier.
Signature: _________________ Date: _________________