LUX GLAMOROUS WIGS & CO.
MEDICAL WIGS | WHERE HAIR CARE MEETS HEALTHCARE
Insurance Verification Form
Patient and insurance information
PATIENT INFORMATION
Patient Name
First Name
Last Name
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone No.
Format: (000) 000-0000.
Work Phone No.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex:
M
F
Diagnosis: INTERNAL USE - DO NOT FILL
Applicable ICD-9-CM Diagnosis code(s)
Anticipated CPT Code(s) for Procedure(s)
PATIENT INSURANCE INFORMATION
Primary Insurance Co.
Policy No.
Group No.
Primary Insurance Phone No.
Format: (000) 000-0000.
Subscriber's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber's Relationship to Patient
Secondary Insurance Co.
Policy No.
Group No.
Secondary Insurance Phone No.
Format: (000) 000-0000.
Subscriber's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber's Relationship to Patient
FOR INTERNAL USE: PLEASE DO NOT FILL OUT
PATIENT ELIGIBILITY AND BENEFITS INFORMATION
Effective Date of Coverage
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Coverage Terminated?
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Plan Type:
HMO
PPO
POS
Other
In-Network Benefits / Co-Payment $
Deductible $
Deductible Met?
Yes
No
Co-insurance $
Other Out-of-Pocket $
Benefits for Treatment?
Yes
No
Is a Referral Necessary?
Yes
No
Is Prior-Authorization Required?
Yes
No
Out-of-Network Benefits?
Yes
No
Out-of-Network Financial Responsibilities?
Yes
No
INSURER INFORMATION
PATIENT ELIGIBILITY AND BENEFITS INFORMATION
Rows
Time of Call
Name of Insurance Rep
Prior-Authorization Phone No.
Prior-Authorization Contact Name
Prior-Authorization Approval No.
Referral Phone No.
Referral Contact Name
Notes:
CPT is a trademark of the American Medical Association (AMA).
Current Procedural Terminology (c) 2008 American Medical Association. All Rights Reserved.
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