Insurance Verification (  ) Primary         (  ) Secondary         (  ) Supplemental

Patient: ________________________  S.S. #______________________  DOB _______________ Insured: _______________________   S.S. # ______________________  DOB _______________ Group #: ____________________  Group Name: _____________________  Claim #: ___________ Insurance ________________________   Address ______________________________________ City _________________________ ST _____  Zip __________   Phone # ____________________ Date:                                       Rep/Adjuster _____________________________________________ Effective Date: ______________ Deductible _______  Family Ded. _______  Ded. Remng ________ Allowable Charge Covered at: ________%  _____________________________________________ Diagnostic, Lab, X-ray Covered at: ______%  ___________________________________________ Out of Pocket _________________  Out of Pocket Met? _____ YES   _____ NO Limitations:  $ ________per Visit       $ _________per Calendar Year # ___________Visits Per Year      # _________Visits Per Month        Review at # ________Visits Are Diagnostic, Lab & X-ray charges included in Limits? ______ YES    ______ NO Accept Assignment?  _____ YES    _____ NO   Signature on File Sufficient?   ____ YES ____ NO Do you Accept Electronic Claims?  _____YES     _____ NO Verify Insurance Name, Address, Group Name and Group #:  Same as above?  ___ YES  ___NO (  ) Self Funded Policy     (  ) Group Funded Policy     Underwriter?   ________________________ If Applicable:  Pre-Existing Conditions are Handled:_____________________________________ If Applicalbe:  Is there and Accident Rider? ___________________________________________ Notes: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________