Insurance Verification Form And Instructions (Page 2 of 2) in pdf

Internal Medicine Associates of Galveston

501 Holiday Dr., Galveston, TX 77550

Phone: 409-771-2040 - Fax: 409-770-9371

Insurance Verification Form

Welcome to our office. Please provide us with the information requested below so that we may assist you in filing your

health insurance forms. All information will be kept confidential.

Patient’s Name:_________________________________________________ Date:___________________

Sex: ____________ Age:_______ Birth Date:________________ Soc. Sec. #:_________________________

Address:_________________________________________________________________________________

City: _____________________________________________________ State: _______ Zip code: __________

Home phone:___________________

Cell phone: ___________________

Email address:____________________________________________________________________________

Spouse’s name (If child, Parent’s name):_______________________________________________________

Name of insurance plan:____________________________________________________________________

Group #:__________________________________

Member ID#:______________________

Insurance holder’s name:__________________________________________ DOB:_____________________

Soc. Sec. #:________________________ Relationship to insured:__________________________________

Address:_________________________________________________________________________________

City: _____________________________________________________ State: _______ Zip code: __________

Employer:________________________________________ Occupation:______________________________

Address:_________________________________________________________________________________

City: _____________________________________________________ State: _______ Zip code: __________

Reason for visit:___________________________________________________________________________

Race:____________________ Ethnicity:___________________ Primary language:_____________________

Emergency contact:_________________________________________ Phone#:_______________________

Internal Medicine Associates will bill the insurer of patient, however patient agrees to pay for the reasonable cost of all

services provided and will be responsible and agrees to pay for any co-pay, deductible, or other charges not paid for by

his insurance company.

_________________________________________________

_______________________

(Patient’s Signature)

(Date)

Insurance Verification Form And Instructions Page 2