|
Scheduling Form |
| Appointment Date: ______________ Time: ___________ Patient Account #: _______________ |
| Name: __________________________________________________ DOB: ___________________ |
| (Last) (First) (MI) |
| Address: ________________________ City, State: _____________________ ZIP: ___________ |
| SS#: ________________________ Phone #: _____________ Work Phone: _________________ |
| Exam: _______________________ Lab: _________________ X-Ray: ______________________ |
| Referring Physicians: __________________________________ Phone #: ____________________ |
| UPIN: _______________________________________________ Fax #: ______________________ |
Primary Insurance |
Secondary Insurance |
|
Carrier: ________________________________ |
Carrier: ________________________________ |
|
Address: _______________________________ |
Address: _______________________________ |
|
City/State/ZIP: _________________________ |
City/State/ZIP: _________________________ |
|
Phone: ________________________________ |
Phone: ________________________________ |
|
Subscriber/Holder: ______________________ |
Subscriber/Holder: ______________________ |
|
Policy# ________________ DOB: __________ |
Policy# ________________ DOB: __________ |
|
Group#: ______________________________ |
Group#: ______________________________ |
|
Auth#: _______________________________ |
Auth#: _______________________________ |
|
Type: COM HMO PPO IPA MC MD |
Type: COM HMO PPO IPA MC MD |
|
Effective Date: ___________Copay: _______ |
Effective Date: ___________Copay: _______ |
|
Deduct: $ ___________ Met: $ ___________ |
Deduct: $ ___________ Met: $ ___________ |
|
Benefits%:__________ Out of Network ____ |
Benefits%:__________ Out of Network ____ |
|
CPE: _________________________________ |
CPE: _________________________________ |
|
Workman's Comp. Claim # _____________________ |
| Patient Employer: ____________________________ Injury Date: __________________________ |
| Employer Address: ___________________________ City/State/ZIP: _______________________ |
| Employer Phone #: ___________________________ Adjuster Name: _______________________ |
| Authorization (circle): Yes No |
| Name of person spoken with: ________________________________________________________ |
| |
| |
|
Name of Verifier: _________________________________ Date: __________________________ |
| |
