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*
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*
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
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
Email
example@example.com
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