Records & Case Management
MRN: Insurance Form
Last Updated:
Insurance Information
Insurance Co: _________________________________
Address: _________________________________
_________________________________
Phone number: _________________________________
Contact Person: _________________________________
Person’s ID #: _________________________________
Group Policy #: _________________________________
Insured’s Name: _________________________________
Social Security #: _________________________________
Employed by: _________________________________
Work Address: _________________________________
_________________________________
Work Phone: _________________________________
Policy Benefits:
Per person deductible: $___________
Family deductible: $___________
Doctor visit co-pay: $___________
Hospital co-pay: $___________
Emergency room co-pay: $___________
Preauthorization required for: (list CT scans, xrays, MRIs, scheduled hospital visits, etc)
___________________________________________________________
___________________________________________________________
Phone number for authorizations: Tests ( ) ______
Hospital ( )___________
Emergency Rooms benefits:
Deductible $____________
Prescription Coverage:
Generic $__________ Brand name $____________
Non-formulary $__________