VERIFICATION OF INSURANCE BENEFITS
Patient:
SS#:
DOB:
-
Month
-
Day
Year
Date
Chief Complaint:
Date of Onset:
1. This is to verify coverage as stated by
On
2. Effective date of coverage
Benefit period
3. Is this a managed care plan?
Yes
No
4. What type of plan? (HMO,PPO,POS)
5. What preferred provider panel does this plan access?
6. (If you are outside the panel) What are the out-of-network benefits?
7. Does this plan require a referral from a primary care physician for maximum benefits for chiropractic service?
Benefits with a referral?
Benefits without a referral?
8. What is the deductible?
Annual?
Case?
9. Is there a co-pay?
Amount?
10. What are the chiropractic benefits and are they subject to deductible and co-pay?
11. Is there a visit limit per year?
12. What is the x-ray coverage?
13. What is the coverage for modalities?
14. What is the coverage for (use CPT codes for specific procedures or products that are being prescribed for the patient such as acupuncture, orthotics, rehabilitation, nutritional counseling or others):
15. (If you are not a member of the plan)Are you currently accepting applications to your plan?
Name and address of contact person:
Submit
Should be Empty: