Insurance Verification Form

Disclaimer: If any of the information in this form is not correctly filled, incomplete or inaccurate, it will result in delay and/or inability to verify your insurance information or to get in touch with you. A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Verification is only a quote of patient benefits. Insurance companies review charges individually and make payment accordingly. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service. Charges not covered by insurance are the patient’s responsibility and are due within 30 days of billing.

Insurance Verification

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Patient Information

Employer's Name

First Name

Last Name

Social Security Number ( Last 4 digits )

Date of Birth

Sex

Male Female Others

Preferred Method of Contact

Patient's Phone Number

Patient's Email

Chief Complaint / Primary Diagnosis

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Information

Insurance Company Name

Phone

Policy Number / ID Number

Relationship to Insured

Group #

Claim # if an Accident

Date of Accident / Injury

Secondary Insurance