Fillable Medical Insurance Verification

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Medical Insurance Verification

On average this form takes 18 minutes to complete

The Medical Insurance Verification form is 1 page long and contains:

  • 0 signatures
  • 13 check-boxes
  • 64 other fields

Country of origin: OTHERS
File type: PDF

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Medical Insurance Verification
Form Made Fillable by eForms
SAMPLE INSURANCE VERIFICATION FORM
PATIENTINFORMATION
Pa
tientName
Pa
tientAddress
Ci
ty STZip
Ho
mePhoneNo WorkPhoneNo
So
cialSecurityNo DateofBirth
M
F
Di
agnosis:
ApplicableICD‐9‐CMDiagnosiscode(s)
An
ticipatedCPTCode(s)forProcedure(s):
PATIENTINSURANCEINFORMATION
PrimaryI
nsuranceCo PolicyNo GroupNo
PrimaryI
nsurancePhoneNo
Subscriber
’sName DateofBirth
Subscriber
’sRelationshiptoPatient
Se
condaryInsuranceCo PolicyNo GroupNo
Se
condaryInsurancePhoneNo
Subscriber
’sName DateofBirth
Subscriber
’sRelationshiptoPatient
PATIENTELIGIBILITYANDBENEFITSINFORMATION
EffectiveDateofCoverage:
CoverageT
erminated?Yes
No Date:
Pl
anType:
HMO PPO POSOther:
In‐NetworkB
enefits:$
Co‐Payment
$
HasDeductibleBeenMet?
Deductible Yes
No
$
$

Co‐insurance OtherOut‐of‐PocketExpense
BenefitsforTreatment?Yes
No
Is
aReferralNecessary?Yes
No
Is
Prior‐AuthorizationRequired?Yes
No
Out‐of‐Network
Benefits?Yes
No
Out‐of‐Network
FinancialResponsibilities?Yes
No
INSURERINFORMATION
CallDate:
TimeofCall:
Nameo
fInsuranceRep PhoneNo/Ext
Prior‐A
uthorizationPhoneNo FaxNo
Prior‐Au
thorizationContactName
Prior‐Au
thorizationApprovalNo
Re
ferralPhoneNo FaxNo
Re
ferralContactName
Notes:
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Medical Insurance Verification

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Completed 31 December 2021

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