Insurance Verification Form

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Patient Info

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Insurance Verification

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Coverage Verification

Is there a health savings account?
Is neuropathy care a covered benefit?
Does it require a referral/pre-authorization?
Has deductible been met?
Are exams covered (99203/99213)?
Are x-rays covered?
Are spinal adjustments covered (98941)?
Are therapies/modalities covered (97012, 97110, 97124, 97140, 97010)?
Can an adjustment be billed on same day as an exam?
Are additional visits allowed with medical necessity notes?
This field is for validation purposes and should be left unchanged.