Insurance Worksheet

Thank you for your interest in our practice, we look forward to meeting you!

We have enclosed this insurance verification form for your convenience. We recommend that you contact your insurance company by using the number on your card and ask the questions listed below and fill in the information on this form. This worksheet was created to help you better understand your insurance policy and coverage.

Insurance Company

Area Code

Phone Number

Spoke to

First Name Last Name

Date

Patient Name

First Name Last Name

Date

Date patient became effective on policy

Does Pre-Existing Condition Apply?

If yes, what is the pre-existing period?

Specialist office visit will be covered by (please select one)

Copay

Deductible & Co-insurance

Copay

Co-Insurance: In-Network %

Co-Insurance: Out-of-Network

Individual Deductible

Individual Deductible Account Met

If applicable, Family Deductible

Family Deductible Amount Met

Out-of-Pocket Individual Amount

Out-of-Pocket Amount Met

If applicable, Family Out-of-Pocket

Family Out-of-Pocket Amount Met

Notes

Insurance Worksheet

Get Started on Your Wellness Journey

Email

Address

Send Us an Email

Quick Links

Service Hours

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