Patient Information
- Full Name: _________________________ Date of Birth: //___
- Address: ________________________________________________
- Phone: (__) - Email: _________________________
Primary Insurance
- Insurance Company Name: __________________________________
- Policy Number: _________________________________________
- Group Number: _________________________________________
- Policy Holder Name: ____________________________________
- Policy Holder DOB: //___
- Relationship to Patient: □ Self □ Spouse □ Parent □ Other
Secondary Insurance (if applicable)
- Insurance Company Name: __________________________________
- Policy Number: _________________________________________
- Group Number: _________________________________________
- Policy Holder Name: ____________________________________
- Policy Holder DOB: //___
Authorization
I hereby authorize [CLINIC NAME] to verify my insurance coverage and benefits. I understand that:
- Insurance verification is not a guarantee of payment
- I am responsible for any copays, deductibles, or non-covered services
- It is my responsibility to inform the clinic of any insurance changes
Signature: _________________________ Date: //___
For Office Use Only
- Verification Date: //___
- Staff Member: ________________
- Coverage Verified: □ Yes □ No
- Copay Amount: $_______
- Deductible: $_______ Met: $_______
- Visit Coverage %: ______
- Authorization Required: □ Yes □ No
- Referral Required: □ Yes □ No