Insurance Card Form

Insurance Card Form

To perform a prior authorization (PA), the key information to collect from an insurance card includes:
Patient Information
Full Name:

First NameLast Name
Member ID Number:
Group Number:
(if applicable)
Plan Information
Insurance Provider Name:
Plan Type (e.g., PPO, HMO, EPO):
Contact Information for the Insurance Provider:
*often a phone number for customer or provider services.
Rx BIN/PCN Numbers (if applicable for medication PA)
*Used for processing pharmacy claims.
Claims and Authorization Contact Information
Phone Number for Prior Authorization or Utilization Management Department:
Fax Number:
*for sending documentation if required.
Payer ID:
*Used for electronic claims and PA submissions in some cases.
Special Notes:
Any specific instructions regarding authorizations or referrals (e.g., pre-approval requirements for certain services).
Additional Details to Collect Separatel
Patient's Date of Birth

MonthDayYear
*Needed to confirm identity.
Provider's Name Information:
Provider's NPI:
Tax ID of the requesting provider:
Service or Procedure Details:
*CPT/HCPCS codes and diagnosis codes (ICD-10).
Supporting Documentation
*Medical records or notes to justify the request.
This information ensures a complete and accurate PA submission, minimizing delays in approval.
Should be Empty: