Insurance Verification Form
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1Gold Star Medical Business Services
866-942-5655
________________
INSURANCE VERIFICATION
DATE:__________TIME:_______
NAME OF CARRIER_____________________________ PHONE_____________________
NAME OF PATIENT _____________________________ DOB ______________________
NAME OF INSURED ____________________________ DOB_______________________
PATIENT RELATIONSHIP TO INSURED: SELF ___ SPOUSE ___ CHILD ___
PATIENT ID # ___________________________ GROUP # ________________________
NAME OF CONTACT _____________ REF # _______________IN-NETWORK Y ___ N ___
1. Is policy in effect?
Y___ N ___ Effective date of policy? _______________
2. Is policy written for a calendar or fiscal year? Cal ___ Fy ___ FY Dates ______ to______
3. Does this policy cover Chiropractic Manipulations (98940, 98941, 98942)? Y___ N ___
4. Does the patient have a deductible to meet? Y___ N ___ (if NO, skip to #8)
5. If yes, is the deductible an Individual or Family deduct?
Ind___ Fam___
6. If yes, how much is the deductible? $_____________Ind $_________________Fam
7. How much of the deductible has been met? $___________ Ind $_____________ Fam
8. Does the patient have a coinsurance?
Y___ N___ (if NO, skip to #10)
9. If yes what is the patient’s coinsurance? _____%
10. Does the patient have a co-pay (fixed $ amount per visit)? Y___ N ___ (if NO, skip to #13)
11. If yes, what is the co-pay? $_______
12. Is this copay for Exams/Office visits only or ALL visits/treatments? ____________
13. What is the patient’s Out-of-pocket max? $______________ Met? ____________
14. Are there any limitations on Chiropractic services? Y___ N ___
15. If YES,
a. Number of Visits _____________ Number of Visits used _____________
b. $ Amount per cal/FY $______________ Amount used $_______________
c. $ Amount per day (Daily capitation/global fee) $_____________________
d. Procedures per day ________________
16. CPT CODES: DO YOU COVER THESE CPT CODES
98943 ___ 97012 ___ 97140___ 97124___
?
97014/G0283 _____ 97110___97112 ___97035___ 97036 ___ 97530 ___ 95907____ XRAY___ EXAM ____
/how many ORTHOTICS-L3020/L3030 ____ L0631 ___ Nutri Coun-97802 ___ E0730____ S8948_____
S9090_____
17.
Are there different benefits for: DME/Orthotics? Y___ N___ X-ray? Y___ N____ (If yes to any item,
describe benefits below in space provided, ask whether preauth is necessary for DME/Orthotics)
18. Is preauthorization required for any services? Y ___ N ___
19. If yes, provide details of preauthorization requirements
_____________________________________________________________________________
MISC/ADDITIONAL INFO ON BENEFITS: ________________________________________________________________
_______________________________________________________________________________________________
ELECTRONIC PAYER ID and/or MAILING ADDRESS for claims:
________________________________________________________________________________________________
________________________________________________________________________________________________
New Patient ___ Established ___ New Policy ___ Update ___ Verified by ___________________________
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