🩺 Insurance Verification Workflow Form
Please complete this form for each new or returning patient prior to their appointment. This information helps us verify insurance eligibility and ensure accurate billing.
Section 1: Patient Information
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of First Appointment
*
 -
Month
 -
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Section 2: Insurance Information
Insurance Name
*
Please Select
Blue Cross Blue Shield/Anthem BCBS
United Healthcare
Cigna
Humana
Tricare
Neighborhood Health
Medicare Part B
Straight Medicaid
Others
Insurance Name not listed
*
Insurance Type
*
PPO
HMO
EPO
Type option 4
Other
Member ID/Policy Number
*
Group number (if applicable)
Subscriber Name
Relationship to Patient
Please Select
Self
Spouse
Parent
Other
Insurance Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Section 3: Verification Details
(This section can be filled out by staff after calling the insurance company.)
Date Verified
*
 -
Month
 -
Day
Year
Date
Verified by
*
Representative name
*
Reference number
*
Eligibility Status
*
Active
Inactive
Pending Termination
Other
Effective Date
*
 -
Month
 -
Day
Year
Date
Termination Date
*
 -
Month
 -
Day
Year
Date
Section 4: Coverage Information
Behavioral Health Coverage Confirmed?
*
Yes
No
Telehealth Covered?
*
Yes
No
Office Visit Covered?
*
Yes
No
Pre-authorization required?
*
Yes
No
Referral needed?
*
Yes
No
Copay/Coinsurance amount
*
Does the deductible apply?
*
Individual Deductible (accumulated/limit)
Family Deductible (accumulated/limit)
Number of sessions allowed per year
Notes from Representative
Section 5: Secondary Insurance (if applicable)
Do they have secondary insurance?
Yes
No
Coordination of Benefits
Section 6: Uploads (Optional)
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Section 7: Admin Notes
Follow-up Action Needed
Please Select
None
Request Authorization
Call Patient
Update Chart
Additional notes/comments
Submit
Should be Empty: