Healthy Practices - James Skoien Dr Of Science Hc LAc
Insurance Verification Form
Insurance Verification
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Email
Phone Call
Contact Number
Patient Information
Employer's Name
First Name
MI
Last Name
Social Security Number
( Last 4 digits )
Date of Birth
Sex
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Others
Preferred Method of Contact
Phone
Email
Patient's Phone Number
Patient's Email
Chief Complaint / Primary Diagnosis
Address Line 1
Address Line 2
City
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Zip Code
Insurance Information
Insurance Company Name
Payer
N/A
Phone
Policy ID / Member ID
Relationship to Insured
Self
Spouse
Child
Others
Group #
Policy Holder First Name
PH MI
Policy Holder Last Name
Policy Holder Sex
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Female
Others
Policy Holder DOB
Subscriber # / ID #
Claim # if an Accident
Date of Accident / Injury
Additional Information
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Employer's Name
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Patient Name
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SSN
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Date of Birth
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Sex
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Preferred Method of Contact
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Patient's Phone Number / Email
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Primary Diagnosis
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Address
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Insurance Company Name
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Insurance Phone
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Payer ID
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Policy ID / Member ID
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Relationship to Insured
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Policy Holder Name
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Group #
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Claim # if an Accident
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Date of Accident / Injury
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