Insurance Form

We offer extensive insurance billing and assistance that includes: checking initially on coverage and letting the patient know up front what
the out-of-pocket cost will be; obtaining letter of necessity and prescription from physician and obtaining pre-authorization; submitting
claims for the patient; appealing denied claims; submitting claims to secondary insurance companies; and weekly checking on
submitted claims and updating patient on status of claims.

          PATIENT INFORMATION:

          Name:

          Address:

          City/State/Zip:

          Home Phone:

          Work/Cell Phone:

          Date of Birth:

          SSN:

          Employer/Student:

          Patient's Relationship to Policyholder: Self    Spouse    Child    Other

          SPOUSES INFORMATION:

          Name:

          Address:

          City/State/Zip:

          Home Phone:

          Alternate Phone:

          Date Of Birth:

          SSN:

          Employer:

          PHYSICIAN INFORMATION:

          Physician's Name:

          Address:

          Phone:

          Fax:

          INSURANCE INFORMATION:

          Insurance Company:

          Address:

          Phone:

          Policy Holder:

          ID#:

          Group #:

          Date:

          Comments
         

Print Assignment of Benefits Form