TRUE Insurance Verification Form
Thank you for choosing TRUE by K. Nicole. This secure form allows us to verify your insurance coverage for a cranial prosthesis (medical wig) related to medical hair loss. Please complete all fields and upload the required documents so we can begin the verification process.
Section 1: Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Gender
*
Please Select
Female
Male
N/A
Section 2: Insurance Information
Primary Insurance Co
*
Policy ID / Member Number
*
Group Number (if applicable)
*
Primary Insurance Phone No
*
Format: (000) 000-0000.
Are you the primary policyholder?
*
Yes
No
If not, list policyholder's name
First Name
Last Name
Policyholder's Date of Birth (if not patient)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber's Relationship to Patient
*
Secondary Insurance Co (if applicable)
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
Section 3: Upload Required Documents
Please upload clear images or PDFs of the following documents. All documents are kept confidential and used solely to verify your coverage for a cranial prosthetic (medical wig).
Front of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Photo ID (Driver’s License or State ID)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Most Recent Explanation of Benefits. Optional but recommended. Your most recent EOB helps our billing team better understand your insurance reimbursement trends and may assist with benefit verification. It does not need to be related to hair loss, just the most recent EOB you’ve received from your insurance provider.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Section 4: Consent & Acknowledgment
Please sign below to allow TRUE by K. Nicole to verify your insurance coverage and communicate with your insurance provider.
Consent Agreement
*
By submitting this form, I authorize TRUE by K. Nicole and its designated billing partners to contact my insurance provider(s) and request information regarding my health benefits, including coverage for cranial prosthetics or medical wigs.I understand that this may include the disclosure and receipt of my personal health information (PHI), such as diagnosis codes, policy details, and other necessary medical or insurance documentation.I affirm that I am voluntarily providing this information and understand it will be used solely for the purpose of verifying benefits and determining insurance eligibility.I understand that TRUE by K. Nicole operates as a HIPAA-compliant Durable Medical Equipment (DME) provider and will use my information in accordance with applicable privacy laws.
Please type your initials to acknowledge and authorize.
*
By entering your initials, you confirm that you have read and agree to the authorization statement above regarding insurance verification and the release of your personal health information (PHI).
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Section 5: Privacy Notice
Your information is secured and protected under HIPAA compliance protocols. This form is used solely for insurance verification purposes related to cranial prosthetics. If you have any questions, please email info@truebyknicole.com.
Submit
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