Insurance Verification Form
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1INSURANCE VERIFICATION FORM
Type of Service: Chiropractic
Physical Therapy
Type of Insurance: Primary
Secondary
Other
Patient Information:
Insured’s Information:
Name: ________________________________________
Name: ________________________________________
Date of Birth: ________________________________________
Date of Birth: ________________________________________
Phone: ________________________________________
Employer: ________________________________________
Relationship: ________________________________________
Insurance Information:
Insurance Company: _____________________________________________
Phone #: ______________________________
Plan Name:
_____________________________________________
Network: ______________________________
Group #: ________________________________________
Subscriber ID: ________________________________________
(Complete information above before contacting insurance carrier)
Verification:
Date/Time Called: ________________________
Ref. Number: ___________
Rep Full Name: ____________ _____________
Yes
No
Calendar
Fiscal
Other
Chiropractic Coverage?
Begins:
Deductible Amount:
Deductible Amount Met:
Out of Pocket Max:
__________________________
__________________________
__________________________
Percentage Covered:
Co-Pay Amounts:
Effective Date:
__________________________
__________________________
__________________________
Yes
No
4th Quarter Carryover? Yes
No
Secondary Insurance Automatic Crossover:
Amount: _________
Are services covered if performed by a chiropractic?
Additional services that may be provided:
Covered Service
Subject to Deductible After Deductible Pays
Covered Service Subject to Deductible
After Deductible Pays
Maintenance Care:
Physical Therapy:*
Spinal Adjustment:
*If physical therapy services are performed by a licensed physical thera-
pist, a separate Insurance Verification Form should be completed.
Extra Spinal Adjust.:
Massage:
Examination:
Acupuncture:
Re-Examination:
Orthotics:
X-Ray:
Modalities: (List specific modalities and verify how many are allowed per visit.)
Limitations:
Yes
No
Does Occupational Therapy or Physical Therapy count towards Chiropractor visit max?
How many Visits: Per Year:_________ Per Diagnosis:________
Max Allowed Per Year: ____________________
Yes
No
Yes
No
Referral or Pre-Authorization Required?
Pre-existing Clause?
Information recorded on this verification form is a quote of your benefits as outlined to us by your insurance company. This information is provided to you as a courtesy
and is NOT a guarantee of payment OR coverage. At your request, we will bill your services to your insurance, however, you are ultimately responsible for your bill.
________ (Patient)
____________ (Date)
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