Insurance Verification Form
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1Insurance Verification Form
Van Every Family Chiropractic Center 248-616-0900
IMPORTANT – please make sure ALL Blanks are completed with information, yes, no, NA, etc.
Patient’s Name____________________________________ Patient DOB_______________
Policy Holder__________________
Employer of PH
_________________________
BCBS
BCN
Cofinity
Priority
Cigna
Aetna (no <3)
Medicare
Med. Adv.
United
Insurance Company ____________________PHONE #______________________________
Policy # or SS# _______________________ Group#________________________________
Medicare # _______________________
Effective Date:_________________________Policy Type:________________HMO?_______
Insurance company called on ______________at____________ am/pm
Talked to: _____________________
Caren+
Auto Fax
Policy is Listed & Active: yes
no Activation Date: ___________
Policy requires a referral:
yes
no
COVERAGE/BENEFITS
IN-NETWORK OUT-OF-NETWORK
LIMITATIONS/MISC.
Individual Deductible Amount: ___________/____________ Amount Met:$___________
Family Deductible Amount:
___________/____________ Amount Met:$___________
Exams:(99202)
___________/_____________ Limitations:_____________
Co-Payments for Exams:
__________/_____________
Limitations:_____________
# of Adjustments(98941)
__________/_____________
Limitations:_____________
% of Adjustments paid at:
__________/_____________
Limitations:_____________
Co-Payments for Adjustments:__________/______________ Limitations:_____________
Dollar max on Chiro. Benefits: __________/______________ Limitations:_____________
Massage Therapy
__________/_______________ Limitations:_____________
______ NO CHIROPRACTIC COVERAGE
Misc.: ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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