Free Insurance Verification Fax Sheet Template
Insurance Verification Fax Sheet
FAX |
|---|
Date: March 8, 2050
To: Oakwood Medical Center
Fax Number: 555-123-4567
From: [Your Company Name]
Fax Number: 888-987-6543
Re: Insurance Verification for Patient
_____________________________________________________________________________________
Message
Patient Information:
Patient: Samantha Johnson
Date of Birth: August 15, 1990
Insurance ID: 0987654321
Group Number: 5432109876
Policy Holder: Michael Johnson
Insurance Coverage Information:
Insurance Company: [Your Company Name]
Effective Date: March 1, 2049
Policy Expiration Date: February 28, 2050
Deductible Remaining: $300.00
Co-Insurance: 90/10 (Insurance pays 90%, Patient pays 10%)
Co-Pay Amount: $25.00
Service Information:
Service Requested: MRI Scan
Provider: Oakwood Medical Center
Date of Service: March 12, 2050
Diagnosis: Code: M54.5 (Low back pain)
Verification Details:
Verified By: Sarah Smith
Date Verified: March 8, 2049
Please contact us if you require any further information or clarification.
_____________________________________________________________________________________
Sincerely,
[YOUR NAME]
[YOUR COMPANY NAME]
[YOUR COMPANY NUMBER]
