Medical Insurance Verification Form
Veterans Wellness Center of Alabama
Patient Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Female
Male
N/A
Social Security Number
*
Back
Next
Insurance
Information
Primary Insurance Co
*
Policy No
*
Group No
*
Primary Insurance Phone No
*
-
Area Code
Phone Number
Secondary Insurance Co
Policy No
Group No
Secondary Insurance Phone No
-
Area Code
Phone Number
Subscriber's Name
First Name
Last Name
Subscriber's Relationship to Patient (Self or Spouse)
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload photo of Front of Insurance Card
*
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of
Upload Photo Back of Insurance Card
*
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of
Notes
Submit
Should be Empty: