Referral Screening & Insurance Verification Form

Referral Screening & Insurance Verification Form
Date Requested
MonthDayYear
Date
How Did You Hear About Us:
Age
Gender
Client Information
Name
First NameLast Name
Date of Birth
Phone Number
Area CodePhone Number
Email
example@example.com
Referral Source
Primary Insurance Information
Name
First NameLast Name
Date of Birth
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Relation to client
Gender
Insurance Carrier
Insurance Carrier’s Phone #
Area CodePhone Number
Member Identification #
Group Identification #
Secondary Insurance Information
Is there a secondary?
Name
First NameLast Name
Date of Birth
Relation to Client
Gender
Insurance Carrier
Insurance Carrier's Phone #
Area CodePhone Number
Member Identification #
Group Identification #
Insurance Verification Notes
Date Effective
Copay Amount
Deductible &/or Coinsurance
MOP
Payor Identification #
Reference #
EAP Pre-Authorization #
EAP # of Vistis
Appointment Date
Medical Record Number
Clinician Assigned
Date Completed & Sent
Should be Empty:

Client Information