Insurance Verification Form

Insurance Verification Form

    Medical insurance claims are necessary to help offset the high costs of healthcare. We’ve built a standardized insurance verification form to help you get medical insurance faster. The document is proofread and features easily replaceable information for customizing to fit your claims. Download it today for free and speed up insurance claim verification.

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Insurance Verification Form
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Insurance Verification Form

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A medical insurance verification form can be used to quickly and accurately verify the eligibility of a patient for insurance claims. Without the use of these forms, the claims denial rate can be high for any company or insurer.

What is an Insurance Verification form?

Medical insurance verification is a complicated process with multiple parties involved in a transaction. Therefore it is quite complex to process. An insurance verification form can ease off some of the tasks involved in processing.

If a medical insurance package covers a person, then it’s the insurance company liable to pay for the medical expenses. To verify the information before providing a service, healthcare providers would send an insurance verification form to the patient’s insurer and other parties. And this process starts with a properly formatted insurance verification form.

Verify your Claims Easily with a Free Insurance Verification Form Template

Avoid the hassle involved in verifying your information in health insurance. We’ve prepared an easy-to-customize insurance verification form sample for you. Get a medical insurance verification form legally with this free template today.

What Is The Insurance Verification Form Template?

An insurance verification form has several fields that must be filled out. Some of them are:

  • Patient name
  • Insurance ID
  • Insurer name
  • Relationship of the insured to the patient
  • The effective date of the policy
  • End date for the policy
  • Limitations of the policy

You can create a medical verification form from scratch or utilize a ready-to-use template. This template contains all of the fields required in an insurance verification form by law. You can download the template, edit the fields to meet your own requirements, and use it for your in-house requirements.

When Is The Insurance Verification Form Used?

The insurance verification form can be used across several conditions and aspects, but the objective remains the same: to verify the information for processing insurance. Hence, these can be used by the following categories of entities:

Insurance companies and agents

Insurance companies often receive many insurance verification forms for insurance payments. To make your life easier as an insurance company, you can provide a single form with a particular format and fields to all of your affiliates. This can ease your task of collecting, processing, and responding to the verification form at your end.

Hospitals

Hospitals have to send verification forms to insurers regularly. Before providing a service, they must verify the eligibility of the patient. Hospitals have a separate billing department that takes care of insurance claims.

Dental And Other Clinics

In addition to hospitals, dental clinics, and other types of clinics need to verify the patient's insurance information from their respective insurers. For dental clinics, there is a separate dental insurance verification form.

Employers

When creating a new contract for an employee, employers might request insurance information from the employee’s existing insurance company. To verify the details, they often send a medical insurance verification form before they offer employee benefits.

Verify your Claims Easily with a Free Insurance Verification Form Template

Avoid the hassle involved in verifying your information in health insurance. We’ve prepared an easy-to-customize insurance verification form sample for you. Get a medical insurance verification form legally with this free template today.

CocoSign has a complete library of health insurance verification form templates that can be used for any industry. You can start using another templates for free. Download the form onto your computer, make the necessary editing, and start using for your own needs.

DOCUMENT PREVIEW

 

Patient Name:____________________________     Patient DOB _______________

Subscriber Name: _________________________     Subscriber DOB ____________

               Employer Name: ______________________________

 

Insurance Company _______________________   Phone #________________

Member ID or SS# ________________________    Group #_______________

Phone #___________________________  Name of Rep: _________________

Claims Address:_____________________________________________________

__________________________________________________________________

 

Effective Date: ____________                Calendar Year or Fiscal Year

Annual Maximum:_______ Used: _______    Annual Deductible:______ Met:____

Deductible Applies to :    Preventive               Basic & Major                  All

Separate Maximum for Preventive:        Yes          No

Preventive: __________ %               Basic: _____________%       Major: ______________%

Perio: ___________%         Endo __________%       Oral Surgery ____________%

Post & Core (D2954) _______%    FMD (D4355) _________%   Buildup (D2950)__________%

Implants ___________%        Nightguards ___________%

FREQUENCY LIMITATIONS:

Comp Exam (D0150) ____________ Limited Exam (D0140) _______________ Periodic Exam (D0120)__________

Perio Eval (D0180) ___________  Bwx(D0274)__________ FMX/PANO (D0210/D0330)___________

Arestin (D4381)______________ Perio Maintenance (D4910)___________ Prophy___________

Sealants  _____________Fluoride ____________________    Nightguards____________

Composites: ____________________  Are composites downgraded        YES        NO

Implants ______________     Scaling & Root Planing ______________     2 quads       or        4 quads

 

Waiting Period for Major?       YES       NO              Crowns/Bridges/Major paid on    Prep    or      Seat

 

Missing Tooth Clause     Yes          No                    Coordination of Benefits ?________________________

INSURANCE VERIFICATION FORM                         DATE:______________________________

 

Other Notes: _________________________________________________________________________

Disclaimer

CocoSign represents a wide collection of legal templates covering all types of leases, contracts and agreements for personal and commercial use. All legal templates available on CocoSign shall not be considered as attorney-client advice. Meanwhile, CocoSign shall not be responsible for the examination or evaluation of reviews, recommendations, services, etc. posted by parties other than CocoSign itself on its platform.

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