Insurance Verification Form
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1Insurance Verification Form
Patient Name
Date of Birth
/
/__________
Phone Number (
)
-
to inform you about your insurance benefits.
Policy Holder: Self
Spouse
Parent
Policy Holder’s Name
Date of Birth
/
/___________
Employment status: Employed
Retired
Unemployed
Student
*Fill in only if applicable.
Employment
Auto Accident Other Accident
Your symptoms are a result of:
Your Claim Number __________________________________
Adjustor’s Name_________________
Adjustor’s Phone Number__________________________
PLEASE READ CAREFULLY AND SIGN THE FOLLOWING:
I authorize the release of any medical
or other information necessary to process claims submitted to my insurance company or the other
responsible party. I also assign the payment of medical benefits directly to Five Branches University
for services provided. I understand that I am fully responsible for my bill and that if attempts to
collect payment from my insurance company / responsible party are not successful, I will remit the
balance due upon notification.
SIGNATURE
Patient / Parent / Guardian
Date
/
/_______
OFFICE USE ONLY:
Insurance Company
___ Phone Number (
)
-_________
Member ID Number
___
Group/Policy Number ____________________
Acupuncture Benefits Yes No
Massage Benefits Yes No
Effective Date
/
/ ____________
Maximum Number of Visits
_
/Week
_ /Month
_
/Year
_
/Condition
Maximum Payable
_ %/Visit
$
_ /Visit
$
_
/Year
$
_
/Condition
Waived Met Single $
Deductible Single $
Family $
Family $_______
Patient Out Of Pocket Single $
Family $_________________
Spoke with
_____
Tracking Number ____________________________________________
Lytec
Chart Sticker
Verified by
Date
/
_/___________
Notes (Including Pre-Auth, MD Referral, Benefits used to date, and other)
__________________________________________________________________________________________
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Parent category: Legal