Patient Eligibility Verification Checklist
Use this form to confirm patient details, coverage information, and eligibility status before the visit or service.
Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Patient ID / Chart Reference
Preferred Contact Method
*
Phone
Email
Text
Coverage and Eligibility Details
Insurance Provider Name
*
Member/Policy Number
*
Plan Type
*
Please Select
HMO
PPO
EPO
POS
Medicare
Medicaid
Self-pay
Other
Group Number
Coverage Active Today?
*
Yes
No
Unsure
Verification Checklist
Identity confirmed
*
Confirmed
Coverage information matches records
*
Matches records
Referral or authorization on file if required
On file
Service/date requested falls within active coverage period
*
Within coverage period
Copay/coinsurance responsibility explained
Explained
Eligibility verified by staff
*
Eligible
Pending review
Not eligible
Service and Visit Details
Requested Department or Service Type
*
Please Select
Primary Care
Pediatrics
Internal Medicine
Cardiology
Dermatology
Gynecology
Orthopedics
Mental Health
Urgent Care
Physical Therapy
Other
Appointment Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Provider Name
Location / Site
*
Reason for Visit or Service Request
*
Notes and Follow-up
Verification Notes
Issue Found During Review
*
None
Insurance inactive
Missing referral
Authorization needed
Coverage mismatch
Other
Follow-up Action Required
*
Contact patient
Request updated insurance card
Obtain referral
Submit authorization
Reschedule
Other
Staff Member Completing Verification
*
Submit Verification
Should be Empty: