Physical Therapy Insurance Verification Form
Patient Information
Full Name
Date of Birth
Phone Number
Address
City
State
Zip Code
Insurance Information
Primary Insurance Company
Policy Number
Group Number
Insurance Phone
Subscriber Name
Subscriber DOB
Relationship to Patient
Verification Details
Effective Dates
Deductible (Individual/Family)
Co-pay / Co-insurance
PT Visits Allowed per Year
Visits Used
Pre-Authorization Required
Yes
No
Notes
Verified By
Verified By (Name)
Date