Verification Form
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Insurance Verification Form
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Staff Verifying
Insurance Rep
Phone
Date
Time
Status
Pending
Completed
Verification ID
Patient & Insured Information
Primary Insurance Company Name
Name of Insured (on card)
Patient Name
Patient Date of Birth
Insured Date of Birth
ID#
Group #
Relationship to Insured
Self
Spouse
Child
Other
Policy Details
Policy Effective Date
In or Out of Network?
In-Network
Out-of-Network
Chiropractic Covered?
Yes
No
Is it an HMO Policy?
Yes
No
Is Care Authorization Needed?
Yes
No
Pre-authorization Needed?
Yes
No
PCP Referral Needed?
Yes
No
Individual Deductible
Amount Met
Family Deductible
Amount Met
Individual Out of Pocket
Amount Met
Family Out of Pocket
Amount Met
Does deductible apply?
Yes
No
Does family deduct need to be met before individual benefits are paid?
Yes
No
Benefits & Coverage
Copay
Co-insurance
Visit Max
Visits Used to Date
Yearly Max
Amount Used
Coverage Details
Exam Covered
X-rays Covered
Modalities Included
Laser (97039)
Does deductible carry over for the 4th Qtr?
Yes
No
Calendar year of plan
Jan-Dec
or
Do the visits to meet the deductible count towards the visit max on the policy:
Yes
No
Claims Information & Notes
Chiropractic Claims Address
Company Name
Address / PO Box
City
State
Zip
Payor ID #
Call Reference & Notes
Reference # for call
Notes
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