Insurance Verification Form printable pdf download

INSURANCE VERIFICATION FORM

DATE:______________________

NAME OF DOCTOR _____________________________ IN-NETWORK Y

NAME OF CARRIER_____________________________ PHONE_____________________

NAME OF PATIENT _____________________________ DOB ______________________

NAME OF INSURED ____________________________ DOB____ __________________

NAME OF CUSTOMER SERVICE REP ___________________________________________

TIME OF CALL: ______________________ REFERENCE NUMBER ___________________

1. Is policy in effect?

2. Effective date of policy?

______________________

3. Is policy written for a calendar or fiscal year?

CAL

4. If FY policy, give dates START _______________ END ________________

5. Does this policy cover ___________________________ (name of specialty, ex:

chiropractic, dermatology, ophthalmology, etc.) SKIP THIS QUESTION IF FAMILY PRACTICE,

GENERAL PRACTITIONER.

6. Does the patient have a deductible to meet? Y

(if NO, skip to #10)

7. If yes, is the deductible an Individual or Family deduct?

Ind

Fam

8. If yes, how much is the deductible? $________________

9. How much of the deductible has been met for the plan year? $___________

10. Does the patient have a coinsurance (pays a % of fee) Y N (if NO, skip to #12)

11. If yes what is the patient’s coinsurance? _____%

12. Does the patient have a co-pay (fixed $ amount per visit)? Y

13. If yes, what is the co-pay? $_______

14. What is the patient’s Out-of-pocket max? $______________ Met? ____________

(FAMILY/GENERAL PRACTICE CLINICS OR PROVIDERS SKIP TO #17)

15. Are there any limitations on (name of specialty) services? Y

16. 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 ________________

e. CPT CODES: (if your specialist performs certain procedures routinely, ask the claims

representative to check those specific CPT codes- customize your form HERE with

those codes

17. Is preauthorization required for services?

18. If yes, provide details of preauthorization requirements

_____________________________________________________________________________

MAILING ADDRESS TO SEND CLAIMS _________________________________________________________________

_______________________________________________________________________________________________

GOLD STAR MEDICAL BUSINESS SERVICES

email:

866-942-5655

Insurance Verification Form

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