Medical Insurance Verification Form
This form is secure and protected under HIPPA guidelines & Regulations.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Gender
*
Please Select
Female
Male
N/A
Insurance
Information
Primary Insurance Co
*
Policy No
*
Group No
*
Primary Insurance Phone No
*
-
Area Code
Phone Number
Secondary Insurance Co
*
Policy No
*
Group No
*
Secondary Insurance Phone No
*
-
Area Code
Phone Number
Submitter Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Signature
I certify that I am authorized to provide the information asked for in this form. I authorize the release of sensitive information on this form to CommonHealth Recovery only to verify and validate the information listed with the aforementioned health plan.
Submit
Company/Account Number
Lead Source
Should be Empty: