Insurance Verification Form printable pdf download

Insurance Verification Form

Patient Name: ___________________________________

Date of Birth: ___________________________________

Insurance Company: ___________________________________

ID #: ___________________________________

1. Do I have Naturopathic coverage?

Yes

2. Beginning date of coverage? __________________________

3. Ending date of coverage? _____________________________

4. Do I need a referral from my primary care physician?

Yes

5. Is the doctor I want to see (Dr. Beck or Dr. Messinger) an In Network

or Out of Network provider? _____________________

6. Is there a Co-pay per visit?

Yes

If so, how much is it? __________________

7. What is the deductible for the year and has it been met?

Deductible $_______________

Amount of deductible met so far $________________

Date ______________

8. Does your insurance cover if a naturopath orders labs or X-rays? Cat

scans or MRIs? Ultrasounds?

Yes

9. Is there a deductible for labs and/or radiology?

Yes

If so, what is it? _____________________

Insurance Verification Form