Get Insurance Verification Request Form (pdf Version)

Filling out the Insurance Verification Request Form is an essential step for obtaining necessary insurance information for your patient. This guide provides you with clear and concise instructions to complete the form online with ease.

Follow the steps to successfully complete your Insurance Verification Request Form.

1. Click ‘Get Form’ button to access the form and open it in an editor that allows you to fill it out online.
2. Indicate whether you have the patient’s written consent to release identifiable information by selecting 'Yes' or 'No.' If 'No,' ensure you obtain consent before proceeding.
3. Fill in the patient information section. Provide the patient's name, date of birth, social security number, and select the insurance type from options such as 'Commercial,' 'Medicare,' 'Worker’s Compensation,' etc. Ensure you also complete the patient’s address details.
4. Input the primary insurance information, including the name of the insurance company, contact details, and the policyholder’s name and relationship to the patient.
5. Enumerate the treatment information by providing the product name and diagnosis codes. This step is crucial as benefits cannot be verified without them.
6. Complete the prescribing physician information, including the physician's name, tax ID number, specialty, and contact information.
7. For secondary insurance, provide the same information as for the primary insurance, including policyholder details.
8. Review all sections to ensure accuracy and completeness of the information provided before finalizing the form.
9. Once you have filled out the form, you can choose to save your changes, download, print, or share the completed form as needed.

Complete your Insurance Verification Request Form online today to streamline the verification process!