Health Insurance Verification Form
Patient Information
Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Non-binary
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Insurance Information
Insurance Provider Name
Insurance Plan Type
HMO
PPO
EPO
POS
Other
Member ID
Group Number
Policy Effective Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy Expiration Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policyholder Information
Is the patient the policyholder?
Yes
No
Name
First Name
Last Name
Policyholder's Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Policyholder
Self
Spouse
Child
Other
Eligibility
1
I confirm that I have reviewed my insurance plan and understand which services are covered.
Covered Services
Consultation / Office Visit
Lab Work / Diagnostics
Imaging (X-Ray, MRI, CT, etc.)
Surgery / Procedures
Physical Therapy / Rehabilitation
Prescription Medications
Prior Authorization Required?
Yes
No
Imaging (X-Ray, MRI, CT,
etc
Prescription Medications
CoPay Deductible Information
2
I authorize the provider and its representatives to use and disclose my insurance and personal information to verify benefits and coordinate payment for healthcare services. I understand that failure to provide accurate information may affect my coverage or result in denied claims.*
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