This insurance verification form summarizes a patient's insurance coverage including their HMO/PPO plan name and policy details, Medicare and Medi-Cal coverage dates, work comp claim information if applicable, and notes on verification of the patient's insurance and authorization for treatment. Key details recorded are the patient's insurance type and numbers, coverage amounts and limitations, and contacts made to verify coverage and notify the plan of the patient's admission.

1. INSURANCE VERIFICATION FORM
Patient Type Insurance Coverage
HMO/PPO/EPO/POS Ins Name Phone
Policy Number Group Number
IPA/Med Group Phone
PCP Phone
Capitated Hospital
Medi BIC# / Medi HIC#
Ins Effective Date
Verified with Phone Number & Extension Not Verified
BENEFITS Copayment Co-Ins %
Deductible Deductible Met IP Copayment
OOP Max OOP Met
Lifetime Max Lifetime Used Patient Liability
MEDICARE Part A Effective Date Part B Effective Date
HIC # Admitted 60 Days? Date Last Admitted
Available Days Acute - Full Co LRSV SNF - Full Co
MEDI-CAL BIC# Coverage
Primary Aid Secondary Aid Specialty Aid SOC Due
Effective Date End Date
WORK COMP Date of Injury Policy Number
Ins Admin Name Phone Number
Billing Address
Claim Number Name of Adjuster Phone
IN CUSTODY Booking Slip Obtained Booking Number
ADMITS Insurance Notified By Facesheet Faxed
Fax Phone Tracking/Ref Number
Authorization Number Authorization given by:
U/R Contact Name U/R Phone
KAISER ADMITS EPRP Notified of Admit (800) 447-3777
Spoke with Admit SC#
Notes
Verified by Date
NRP 3/1/13
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