Plastic Surgery Patient Insurance Verification Form

Patient Information

• Full Name: ________________________
• Date of Birth: //____
• Insurance ID: _____________________
• SSN (last 4): XXX-XX-_______

Primary Insurance Details

• Insurance Company: ________________
• Plan Type: □ PPO □ HMO □ Other
• Policy Holder Name: ______________
• Relationship to Patient: ___________
• Group Number: __________________

Coverage Verification

Plastic Surgery Benefits

• In-Network Deductible: $_________ Met: $_________
• Out-of-Network Deductible: $_________ Met: $_________
• Co-Insurance: _________%
• Prior Authorization Required: □ Yes □ No

Procedure-Specific Information

• CPT Code(s): __________________
• Diagnosis Code(s): _____________
• Pre-certification Number: ________
• Coverage Limitations: ___________

Authorization Details

• Date Verified: //____
• Representative Name: ___________
• Reference Number: _____________
• Authorization Valid Until: //____

Special Notes

□ Cosmetic Exclusions □ Medical Necessity Requirements □ Documentation Requirements

Staff Verification

• Verified By: ___________________
• Date: //____
• Time: : □ AM □ PM

This form must be completed prior to scheduling any surgical procedure