Patient Information
- Full Name: _________________ Date of Birth: _________________
- Address: _________________ City/State/ZIP: _________________
- Phone: _________________ Email: _________________
- SSN: _________________ Gender: □ M □ F
Primary Insurance
- Insurance Company: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _________________
Secondary Insurance (if applicable)
- Insurance Company: _________________
- Policy Number: _________________ Group Number: _________________
- Policy Holder Name: _________________ DOB: _________________
- Relationship to Patient: □ Self □ Spouse □ Parent □ Other: _________________
Procedure Information
- Scheduled Procedure: _________________
- CPT Code(s): _________________
- ICD-10 Code(s): _________________
- Scheduled Date: _________________ Time: _________________
Pre-Authorization
- Pre-authorization Required? □ Yes □ No
- Authorization Number: _________________
- Valid Date Range: _________________ to _________________
- Number of Visits Approved: _________________
Patient Financial Responsibility
- Estimated Deductible Remaining: $_________________
- Coinsurance %: _________________
- Copay Amount: $_________________
- Out-of-Pocket Maximum: $_________________
Verification Details
- Date Verified: _________________
- Staff Member: _________________
- Insurance Rep Name: _________________
- Reference Number: _________________
Authorization
I hereby authorize the release of any medical information necessary to process insurance claims related to my vascular surgery care. I authorize payment of medical benefits directly to the physician/facility for services rendered.
Patient Signature: _________________ Date: _________________