Patient Insurance Verification Template - 2013 printable pdf download

PATIENT INSURANCE VERIFICATION

Please call the 800 phone number on the back of your insurance card and ask the following questions:

Patient Name:___________________ Date of Birth: _________ Insurance Company: ________________

Patient ID #: ____________________

(ASHN-American Specialty Health Network and Kaiser Is not accepted for acupuncture)

1. Name of representative I am speaking with_____________________________Date/Time__________

2. When did my coverage begin and is it still current, until when?

Beginning Date of Coverage__________

Current: Yes or No

Ending Date of Coverage__________

3. Do I need a referral from my primary care physician (PCP) for alternative services? Yes or No

4. Is Stacey Raffety, ND,LAc In-Network or a Preferred Provider with my insurance company? Yes or No

5. What are my benefits? SEE Below

There will be different benefits depending on whether the doctor is In-Network

or Out-of Network, and whether your plan includes Out-of-Network benefits.

Naturopathic:

Deductible _________ Met __________ Waived Yes or No

Co-pay $______ or Co-Insurance ______% Number of Visits/or $________ per year

Acupuncture:

Co-pay$______ or Co-Insurance ______%

Number of Visits/or $________ per year

Is this a combined benefit with acupuncture, naturopath & chiropractic? Yes or No

Lab Work:

Deductible ____________ Met _____________ Waived Yes or No

Lab benefit

Co-pay $______or Co-Insurance _______% Max $___________ per year

*Can my Naturopath order my labs? Yes or No Does the lab work go towards my Naturopathic benefits?

Yes or No

*What are the preferred labs? Labcorp, PamL Labs, Quest or Other: ______________________________

6. What year is my deductible based on?

□ Calendar Year

Policy Year

□

ASSIGNMENT OF INSURANCE BENEFIT AND VERIFICATION ACKNOWLEDGMENT

I acknowledge that the above listed coverage information is valid and correct. I understand that benefit verification is not a guarantee of

coverage by my insurance company, and that I am financially responsible for all the services rendered to me by Tigard Holistic Health Clinic

(THHC) and its practitioners. I also understand that all out-of-network (non-contracted) insurance billing services provided by THHC on my

behalf are performed on a courtesy basis and can be discontinued by either myself or THHC with written notice at any time. I authorize

release of information in my medical history to my insurance company and assign all benefits for unpaid services to the providers(s) at THHC.

A photocopy of this authorization shall be considered as effective as the original. Assignment will remain in effect until revoked by me in

writing.

____________________________________________________________________________________

Signature

Print Name

Date

Must be signed or verification VOID

Tigard Holistic Health Clinic

11930 SW Greenburg Rd Tigard, OR 97223

Phone: (503)639-1712

Fax: (971)249-0319

Patient Insurance Verification Template - 2013

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