Insurance Verification Information Form
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1Insurance Verification Information
Doctor
C A Initials
Verified on
Patient #
Computer #
Case type
Patient Name
D O B
Insured’s name
D O B
Relationship
Since (Date)
Injured / ill since
Employer
Phone
Address
Supervisor
City
State
Zip
Note
Insurance Company
Phone
Address
Insured’s ID
City
State
Zip
Group #
Contact
Title
Phone
Claim #
Notes
Primary or
Secondary insurance
Diagnosis
Treatment prescribed
Policy effective from
Deductible amount
per year
Deductible met?
Max payment for
initial visit
Max payment
covered per visit
Max ceiling for X-ray
and other
diagnostics
Max number of visits
covered per year
Items expressly not
covered
Items requiring
specific tests &
confirmation
Other notes and
comments
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Parent category: Legal