Thrive Insurance Eligibility Check Form

Thrive Insurance Eligibility Check Form

Complete this insurance eligibility check form based on the attached PDF. Provide accurate insurance and appointment details, upload both sides of your insurance card, and review the required acknowledgments before signing.
Applicant Information
Full Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance Information
Insurance Company
Plan Name / Type
Member ID
Group Number
Policyholder Details
Patient is the primary policyholder
Patient is NOT the primary policyholder
Policyholder Full Name

First NameMiddle NameLast Name
Policyholder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
Insurance Card Uploads
Insurance Card - Front

Cancelof
Insurance Card - Back

Cancelof
Planned Appointment Type
Planned Appointment Type

Other
Other Planned Appointment Type
Consent and Authorization
I understand that insurance verification does not guarantee payment by my insurance company (I Agree)
I understand that my benefits may change before my appointment (I Agree)
I understand that I am responsible for applicable copays, deductibles, coinsurance, non-covered services, and other patient responsibility (I Agree)
I understand that some plans may require a referral, prior authorization, or designated primary care provider (I Agree)
I confirm that I provided clear images of BOTH the FRONT and BACK of my current insurance card (I Confirm)
I authorize Thrive Women's Primary Care Clinic P.C. to use the insurance information I provided to verify eligibility and benefits related to my anticipated healthcare services (I Authorize)
Patient / Responsible Party Name

First NameMiddle NameLast Name
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Thrive Insurance Eligibility Check Form

Applicant Information

Insurance Information

Policyholder Details

Insurance Card Uploads

Planned Appointment Type

Consent and Authorization