Physical Therapy Insurance Verification Form
Patient Name
Date of Birth
Phone Number
Insurance Company
Insurance Phone
Policy Holder Name
Policy Holder Date of Birth
Policy Number
Group Number
Relationship to Policy Holder
Self
Spouse
Child
Other
Diagnosis / ICD-10 Code
Insurance Representative Contacted
Date Verified
Physical Therapy Coverage Verified
Yes
No
Insurance Benefits / Coverage Details
Visit Limitations / Auth Required
Copay / Coinsurance / Deductible Details
Notes