Insurance Verification Form

Insurance and Payer Verification Form
**IMPORTANT: If you have already submitted your most current insurance and payer information for your NEXT appointment through this form you do not need to submit it again**
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Next Appointment*

MonthDayYear
Date
Select which one applies to you *If you have already been seen in 2024 under your updated insurance you do not need to submit again:*

I (1) have NEW insurance from when I was in last, (2) have NEW insurance for 2024, OR (3) I am a NEW PATIENT and this is my first appointment (complete information below).I am not a New Patient and my insurance has not changed since I was in last (2023 or previous years) .I am using Self Pay.
Please Note: As of January 1, 2024 we are In-Network with:
- Cigna
- Aetna
- UnitedHealthcare (excluding Navigate plans, Doctors Plans and Medicare Supplemental plans)
- Humana
- GEHA
- Health Partners
- Christian Brothers
- Friday Health Plans
- and subsidiaries of these companies
We do have Self Pay options available for Carrier's we are Out of Network with - please reach out and ask!
Insurance Information
Primary Insurance Company AND Plan Name [E.g. UHC Choice Plus, UHC Navigate, Cigna Open Access Plus etc]
Primary Ins Policy Number/User ID/Member ID)
Primary Group Number
Primary Insurance Phone Number (For Provider Line)

Area CodePhone Number
Primary Subscriber's Name (If the main subscriber on the account is not you)

First NameLast Name
Primary Ins Subscriber's Date of Birth (if main subscriber on the account is not you)

MonthDayYear
Date
Subscriber's Relationship to Patient
Secondary Insurance Co
Secondary Policy No
Secondary Group No
Secondary Insurance Phone No

Area CodePhone Number
Secondary Subscriber's Name (if the main subscriber is not you)

First NameLast Name
Secondary Ins Subscriber's Date of Birth (if the main subscriber is not you)

MonthDayYear
Date
Subscriber's Relationship to Patient (Secondary Ins)
Is your treatment under contract with either Injury Finance, Workman's Comp or an Auto Accident Claim?

YesNo
Please Select One (Note: Detailed claim information will be collected on your intake)

Injury FinanceWorkman's CompAuto Accident ClaimOther
Is there anything else we need to know or other information that needs to be updated in your account? (Phone, email, address etc)
Should be Empty:

Insurance and Payer Verification Form

**IMPORTANT: If you have already submitted your most current insurance and payer information for your NEXT appointment through this form you do not need to submit it again**

IMPORTANT: If you have already submitted your most current insurance and payer information for your NEXT appointment through this form you do not need to submit it again