Smart PDF Form

Tend Natural Health is committed to providing the best care for patients. As a service, we bill insurance carriers directly. However, patients are responsible for all charges resulting from treatment by their provider. We require patients to check benefits before their first treatment. It is the patient's responsibility to be aware of her/his benefit coverage, deductible, co-pay, and coinsurance amounts. We ask that you fill out this form to the best of your knowledge.
Your Name:
Date of Birth:

MonthDayYear
Date
Member ID Number:
Insurance Carrier Name:
Please call the customer service number from the back of your ID card and ask the following questions:
Call Date:

MonthDayYear
Date
Call Time:

Hour Minutes

AM/PM Option
Name of Representative
Call Reference Number
What is the date my coverage began?

MonthDayYear
Date
YesNo
"In network""Out of network"
YesNo
YesNo

TEND
natural health
What is my deductible? $
How much have I met to date? $
YesNo
Is a prior Authorization required for any of the above services?
YesNo
Assignment of Insurance Verification and Benefits Acknowledgement
I acknowledge that the above listed coverage information is valid and correct. I understand that benefit verification is not a guarantee of coverage by my insurance company, and that I am financially responsible for all services rendered to me by Tend Natural Health.
Responsible Party Signature

Clear
Should be Empty: