Insurance Verification | Karen Buckley

You are 100% responsible for all services rendered. Insurances typically only cover a portion of your bill. You may also be subject to Co-Pays and Deductible. It is your responsibility to contact your insurance plan to understand what they will cover. In any event you are responsible for all incurred services and are expected to pay your bill on time.

Do you have insurance?

Yes

Section

Secondary Insurance Information

Same information as above

Yes

First Name

Last Name

Secondary insurance compay name

Date of Birth

Secondary insurance Policy or ID number

Address

City

State/Province

Zip/Postal

Phone

Secondary Insurance Policy or ID number

Are you the primary on the insurance?

yes

First name of Primary

Secondary insurance group number

Last name

Date of birth of primary

Secondary Insurance phone number

I agree to Billing and Payment terms

Yes

Date

If payments are not made on time all future appointments will be canceled until your balance is paid in full.

I agree

Date

Phone

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Insurance Verification Form

Section