Insurance Payment Tracker Template
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1Insurance Payment Tracker
Doctor
Date
Patient #
Case type
Patient Name
D O B
Insured’s name
D O B
Relationship
Since (Date)
Injured / ill since
Employer
Phone
Address
Supervisor
City
State
Zip
Note
Insurance
Phone
Company
Address
Insured’s ID
City
State
Zip
Group #
Contact
Title
Phone
Claim #
Notes
Insurance Payment
Primary
Secondary
Insurance:
Insurance:
Diagnosis & Treatment:
Insurance Company Section
Reasons for pending claim (If applicable); or date and details of claim payments made or expected shortly:
If claim has been denied, the reasons given:
Have patient and/or medical facility been informed about the status?
Other notes and comments
Name &
Contact
Signature
details
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Parent category: Legal