SPMBS Insurance Verification Form

Medical Insurance Verification

Eligibility Request Form
Patient Information
Patient Name*

First Name Middle NameLast Name
Name of Provider/Therapist*
NAME OF YOUR PROVIDER
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*
Format: (000) 000-0000.
Patient Email*
example@example.com
Patient Date of Birth*

MonthDayYear
Date
Patient Gender*
Patient SSN*
Insurance Coverage
Primary Insurance of Patient*
Subscriber ID*
Group No*
Primary Insurance Phone No*
Format: (000) 000-0000.
Subscriber's Name (this is the family member who this policy is under)*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber SSN*
Subscriber's Relationship to Patient*
Secondary Insurance (if you have one please enter info, if not then you can skip this step)
Secondary Insurance Co
Subscriber ID
Group No
Secondary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Subscriber's Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Upload Front of Your Drivers License or State issue ID*

Cancelof
Upload Front of Insurance Card*

Cancelof
Upload Back of Insurance Card*

Cancelof
*

I certify that I (or my dependent) have insurance coverage with the identified agency/agencies, and assign directly to all benefits, if any, directly payable to the provider, for services rendered. I understand that I am financially responsible for all charges whether or not paid by the insurance. I hereby authorize the clinical staff of the provider to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
I certify that the signature below belongs to me. I have signed this signatutre to the best of my ability with the smooth signature option provided on this form. I will not use an "X" or scribble. / Certifico que la firma a continuación me pertenece. He firmado esta firma lo mejor que he podido con la opción de firma suave proporcionada en este formulario. No usaré una "X" ni garabatos.*

THIS IS MY SIGNATURE!
Signature*
I am...*

The PatientThe Parent/Legal Guardian
Please verify that you are human*
Notes
Should be Empty:

Medical Insurance Verification