Insurance Verification Form printable pdf download

Insurance Verification Form

Insurance Verification Form:

As a courtesy to you, at the time of your initial visit we will contact your insurance

company to verify your benefits. When called from our office the insurance representative

informs us that “this is a quote of benefits and does not guarantee coverage, all benefits will

be determined at the time of claim submission”. Because of this we recommend that all

patients also call their insurance company to verify benefits for themselves.

Below is a set of questions that we suggest you ask the representative during your

conversation. The telephone number to call is usually on the back of your card.

Name of representative:___________________________________ Date and Time:______________________

Does my plan have chiropractic benefits? Yes or No

Do I need a referral from my primary care doctor? Yes or No

Do I have a deductible? Yes or No if yes what is the amount? __________ has any been met?

Do I have a co-pay or co-insurance? _______________ or _________________%.

Is there a limit on the number of visits? Yes or No ____________

Is there a max dollar value per visit? _____________________

(sometimes insurance will pay $40 max/visit)

Is there a dollar limit per year? ______________________________

Confirmation Number of this conversation: ______________________________________________

If you still have questions please do not hesitate to contact our office to discuss your

insurance. We also recommend that you bring in your quote of benefits, so we can compare

it to our quote of benefits.

Commonly used codes in our office:

Procedure

Codes

Coverage

Examinations

99203, 99213

Y or N

Spinal Manipulation

98941, 98943

Y or N

Rehab/Stretching

97110, 97112, 97530

Y or N

Soft Tissue

97140

Y or N

Insurance Verification Form