Get Manual Benefits Investigation

This guide provides a comprehensive overview of the MANUAL BENEFITS INVESTIGATION form, designed to assist users in efficiently gathering and submitting necessary patient information and insurance details. Follow these clear steps to successfully complete the form online.

Follow the steps to effectively fill out the MANUAL BENEFITS INVESTIGATION form.

1. Click the ‘Get Form’ button to access the MANUAL BENEFITS INVESTIGATION form and open it in your preferred editor.
2. In the patient information section, provide the patient's name (first, middle initial, last), date of birth in MM/DD/YYYY format, and address, including city, state, and ZIP code. Additionally, include the home phone number.
3. Enter the patient’s email address and cell phone number. Specify the best time to contact the patient.
4. In the insurance information section, indicate whether the patient has insurance and check all applicable options, including private insurance, VA/Military, state assistance, Medicaid, or check the box if the patient does not have insurance. Provide details for Medicare, including parts A, B, D, advantage, or other, if applicable.
5. Fill in the primary insurance information including the insurance telephone number, policy ID number, and group number. If applicable, complete the secondary insurance details.
6. Include information on the pharmacy plan, such as the plan name, phone number, policy ID number, group number, RX bin, and RX PCN.
7. For the prescriber information section, provide the prescriber’s name (first and last), NPI number, practice name, office contact details, and address including city, state, email, ZIP code, and phone number. Include the tax ID number and state license number.
8. In the clinical information section, state the diagnosis, marking V25.11 or other, as necessary.
9. For physician attestation, the prescriber must sign the form to certify the medical necessity of therapy with , providing the insertion date, and ensuring they have HIPAA authorization from the patient to release medical information.
10. Upon completion, review all entered information for accuracy. Save the changes, then download, print, or share the form as needed.

Complete your MANUAL BENEFITS INVESTIGATION form online today for efficient management of benefits.