Insurance Information Form

Insurance Information

Patient and Policyholder Details

Please provide your current insurance details to facilitate accurate billing and benefit verification. Ensure all information matches your insurance card to prevent delays in processing your claims.

Patient First Name *

Patient Last Name *

Email Address *

Phone Number *

Patient Date of Birth

Is the Patient the Policyholder?

Yes

If No, Policyholder Full Name (If different from patient)

Policyholder Date of Birth

Policyholder Relationship to Patient

Spouse

Parent

Other

Policyholder Phone Number

Primary Insurance Information

Insurance Company Name : (e.g., Aetna, Blue Cross, Medicare, Medicaid)

Member ID Number

Group Number

Plan Phone Number (Back of Card)

Effective Date of Coverage

Type of Plan

HMO

PPO

POS

EPO

Medicare

Other

Authorization/Referral Required?

Yes

If Yes, Authorization Number

Secondary Insurance Information (If Applicable)

Secondary Insurance Company Name

Secondary Member ID Number

Secondary Group Number

Secondary Policyholder Name (if different)

Assignment of Benefits & Release of Information

Assignment of Benefits: I hereby instruct and direct my insurance company to pay the practice directly for professional services rendered. I understand that I am financially responsible for any co-payments, deductibles, co-insurance, or non-covered services not paid by my insurance company.

Release of Information: I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original.

Patient/Policyholder Signature

Use your mouse or finger to sign in the box below.

Date

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Insurance Information Form

Insurance Information Form

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