American Regent Iv Iron Reimbursement Hotline Insurance Verification Request Form
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1American Regent IV Iron Reimbursement Hotline
Phone: (877) 4-IV-IRON
Insurance Verification Request Form
Fax: (240) 632-3805
PLEASE COMPLETE ALL SECTIONS AND FAX TO: (240) 632-3805. The American Regent IV Iron Reimbursement Hotline will contact the insurance
company or companies listed below to determine coverage for Venofer and/or Injectafer as requested.
Name of Contact
Completing Form
Phone Number
PATIENT INFORMATION
PATIENT’S CONSENT IS REQUIRED TO CONDUCT INSURANCE RESEARCH
By providing consent, the patient authorizes us to contact the
insurer to conduct research and relay the patient’s name, date of birth, social security number, diagnosis, and insurance information.
Do you have the patient’s consent on file? YES
NO
PATIENT NAME:
Address:
Phone Number:
(
)
Date of Birth:
Social Security Number:
DIAGNOSIS AND OTHER PERTINENT MEDICAL INFORMATION
Venofer
Injectafer
PRODUCT REQUESTED:
Anticipated Date of Service:
________________________________
Primary Diagnosis
Secondary Diagnosis
Diagnosis
__________
___________
Physician’s Office Hospital Outpatient Other (please specify):
Setting of Care
_________________
INSURANCE INFORMATION
PRIMARY INSURANCE:
(Insurer Name and State)
YES NO
Participating Provider:
Payer Provider Number: ________________________________
Phone Number:
(
)
Fax Number:
(
)
Policy Holder’s Name:
Social Security Number:
Date of Birth:
Employer’s Name:
Policy Number:
Group/Plan Number:
SECONDARY INSURANCE:
(Insurer Name and State)
YES NO
Participating Provider:
Payer Provider Number: ________________________________
Phone Number:
(
)
Phone Number:
(
)
Policy Holder’s Name:
Social Security Number:
Date of Birth:
Employer’s Name:
Policy Number:
Group/Plan Number:
If you have tertiary insurance, please fill out an additional Insurance Verification Request Form.
PHYSICIAN INFORMATION
PRESCRIBING PHYSICIAN
NAME:
NPI Number:
Tax ID Number:
Facility Name:
Address:
Provider Specialty:
DEA Number:
Phone Number:
(
)
Fax Number:
(
)
IF PA IS REQUIRED WOULD YOU LIKE US TO INITIATE THE PA PROCESS? YES
NO
FCM102 Iss. 7/2015
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