Insurance Verification Form printable pdf download

Insurance Verification Form

: ___________

Appointment

Today’s Date: __________________________________

Primary Member:

Patient’s Name: _________________________________

Name: _____________________________________________

Patient’s DOB: _________________________________

DOB: __________________Last 4 of SS# ________________

Routine Vision:

Notes: _____________________________________________

___________________________________________________

Insurance Company: _____________________________

Representative’s Name: __________________________

____________________________________

________

Reference #: ________________________________

____________________________________

________

Policy ID #: ____________________________________

___________________________________________________

Group #: ______________________________________

____________________________________

________

Effective Date of Coverage: _______________________

____________________________________

________

Co-pay Amount: ________________________________

____________________________________

Deductible Amount: _____________________________

________

Amount of Deductible Met: _______________________

____________________________________

________

Allowable Amount to Collect on Deductible: _________

____________________________________________________

Is Refraction Covered? ___________________________

Secondary:

In network____ Out of network____

Medical Exam:

In network____ Out of network____

Insurance Company: ___________________________________

Insurance Company: __________________________________

Representative’s Name: ________________________________

Representative’s Name: _______________________________

Reference #: ________________________________________

Policy ID #: _________________________________________

Group/Plan #: ________________________________________

Group #: ____________________________________________

Effective Date of Coverage: ____________________________

Effective Date of Coverage: ________________________

Co-Pay Amount: _____________________________________

CoPay Amnt: __________Coinsurance:__________%

after deductible

has been satisfied

Deductible Amount: __________________________________

Deductible Amount: _____________/____________________

Individual / Family

Amount of Deductible Met: ____________________________

Amount of Deductible Met: ___________/_________________

Individual / Family

Allowable Amount to Collect on Deductible: ______________

Allowable Amount to Collect on Deductible: _______________

Covers MCR 20% Coinsurance _________________________

Exam to Copay _________ Testing to Copay___________

Covers MCR Part B Deductible__________________________

Exam to Deductible________ Testing to deductible________

____________________________________________________

OOP Max:______________ OOP Met:_________________

Insurance Verification Form

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