SAMPLE FORM:COPY, PASTE and EDIT.
____ Date Scheduled
____Not Scheduled
Procedure for Patient Insurance benefit verification:
The attached form shall be filled out
in its entirety. Then fax document to the billing center each day with the patient information sheet.
NAME:_________________________________________
SS#____________________________
DOB __________
MVA_____ WC______ OTHER______ DOI_________
INSURANCE COMPANY_________________________
INSURANCE
CO. PHONE #_______________________
INSURANCE POLICY #__________________________
REF. PHYSICIAN____________ ICD-9_______
PATIENT
PHONE # THEY CAN BE REACHED DURING THE
DAY__________________________
It is important the patient be told they
will be notified if approval cannot be obtained.
______ Out-of-Network Can we treat the patient? ______yes ______no
______
Patient will have deductible ______ Amount _____Met ______Benefit %
______ Pre-Cert. Required _____ one time _____
each visit _____ required after eval.
______ Special requirements:
Address to send claim to:___________________________________________________
Claim
Attn. To:___________________________________Person spoke to:__________
EDI #____________ Date____________ Verified
by_______________
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