Insurance Verification

Insurance Verification Form

- In-Network
- Out-of-Network
- Primary
- Secondary
First Name:
Last Name:
Date of Birth:
Insurance Company:
Insurance Phone Number:
Insured's Name:
Insured's Date of Birth:
Group Number:
Insured's Policy ID Number
Effective Date of Policy:
Pre-Existing Waiting Period:
Policy Year?
- Yes
- No
Policy Year:
Calendar Year?
- Yes
- No
Calendar Year:
Pre-Certification?
- Yes
- No
Individual Deductible Amount:
Individual Deductible Met:
Carry Over? (Individual Deductible)
- Yes
- No
Family Deductible Amount:
Family Deductible Met:
Carry Over? (Family Deductible)
- Yes
- No
Co-Insurance:
Co-Payment:
Out-of-Pocket Max:
Out-of-Pocket Met:
Authorization Required?
- Yes
- No
Notes:
Authorization Contact Information (if applicable):
Is the annual maximum:
- HARD
- SOFT
Benefit Max:
Dollar Amount:
Used:
Visit Maximum:
Visits Used:
Is the benefit max?
- Per Condition
- Annual
- Based on Medical Necessity
Is there a daily limit?
Dollar amount? Unit Restriction?
Policy Exclusions: Are there any policy exclusions such as TMJ, manipulations, or pre-existing condition?
Any restrictions or exclusion for CPT codes 97140 and 97112?
Insurance Representative Name:
Reference # or Employee ID #:
Notes:
BENEFIT DISCLAIMER: Please note this is a quote of benefits and not a guarantee of payment by your insurance. Final determination of a claim payment will be made once your insurance company received your claim for services rendered. Deductible and out of pocket amounts will change as additional claims are processed by your insurance.
Verified By:
Date Verified:

SAVE AND SEND TO [email protected]

Insurance Verification

Insurance Verification Form

Body Gears Physical Therapy Chicago Lincoln Park

Body Gears Physical Therapy Oak Brook

Body Gears Physical Therapy Oak Park

Body Gears Physical Therapy Winnetka

Dollar amount?	Unit Restriction?