AMERITEK MEDICAL BILLING SERVICE,INC

Electronic Medical Billing and Full Practice Management

Form-Ins.Verification

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_______________