6
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:
ApplicableICD9CMDiagnosiscode(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:
InNetworkB
enefits:$
CoPayment
$
HasDeductibleBeenMet?
Deductible Yes
No
$
$

Coinsurance OtherOutofPocketExpense
BenefitsforTreatment?Yes
No
Is
aReferralNecessary?Yes
No
Is
PriorAuthorizationRequired?Yes
No
OutofNetwork
Benefits?Yes
No
OutofNetwork
FinancialResponsibilities?Yes
No
INSURERINFORMATION
CallDate:
TimeofCall:
Nameo
fInsuranceRep PhoneNo/Ext
PriorA
uthorizationPhoneNo FaxNo
PriorAu
thorizationContactName
PriorAu
thorizationApprovalNo
Re
ferralPhoneNo FaxNo
Re
ferralContactName
Notes: