Insurance Verification Form printable pdf download

Practice Name

Doctor Name, M.D.

Address, City, State Zip



Phone

Fax

Thank you for your interest in our clinic. We look forward to meeting you!

We have enclosed this insurance verification form for your convenience. We recommend that you

contact your insurance company by using the number on your insurance card and ask the questions

listed below and fill in the information on this form. This form was generated to help you better

understand your insurance policy and coverage.

Insurance Company: __________________________

Phone: _________________________________

Spoke To: ___________________________ Date: __________ Time: ___________

Patient Name: ___________________________

Policy Holder Name: __________________________

Date patient became effective on policy: __________

Does Pre-Existing Condition Apply?

YES

If YES, what is the pre-existing time period? _______________________________________________

Specialist Office Visit will be covered by (please circle):

Co-Pay

Deductible and Co-Insurance

Co-Pay $________

Co-Insurance: In-Network % ______

Co-Insurance: Out-of-Network % ______

Individual Deductible

$________

Individual Deductible Amount Met

$ ________

If applicable, Family Deductible

$ ________

Family Deductible Amount Met

$ ________

Out-of-Pocket Individual Amount

$ ________

Out-of-Pocket Amount Met

$ ________

If applicable, Family Out-of-Pocket

$ ________

Family Out-of-Pocket Amount Met

$ ________

How will my insurance policy cover a hearing test (CPT 92557), if the test is done on the same day as my office visit?

This test is non-routine and will be billed with a medical diagnosis, and is not for the fitting of a hearing aid.

_____________________________________________________________________________________

If diagnostic/machine tests are performed at a later date, and no office visit will be billed on the same day as the

testing, how will benefits be considered? ________________________________________________________

If diagnostic/machine tests are performed and an office visit will be billed on the same day, how will benefits be

considered? _______________________________________________________________________________

Notes:

___________________________________________________________________________________________________

The items listed on the attached sheet are only an example of the tests (machine tests/diagnostic tests) that may be

performed in our office. All of the tests below will not be performed on every patient, but the list has been provided

to help you determine how your insurance will consider benefits for services that will be performed in our office.

Insurance Verification Form

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