Insurance Verification Form - BKD.com

Insurance Verification Form Resident Full Name __________________________________________________ SSN ____-____-_____ Projected Admission Payor:

DOB ___/___/____

□Male □Female □Private Pay □Medicare A □Medicaid □Medicaid Pending □Insurance Insurance Verification

Insurance Primary Payor _____________________________________________________________________________________ Phone # ____-____-____ Policy # ________________________________ Billing Address (if not on card) ___________________________________ Out-of-Pocket $ _________

□Met □Not Met

If insurance primary, how are services reimbursed? □Levels □RUGs □Charges □Other

In-network □Yes □No Authorization required □Yes □No Re-authorization required □Yes □No Authorization # __________________ Authorization Date Span ____________________________________ Pre-hospitalization required □Yes □No

If yes, dates of hospital stay ____________________________

Medicare Supplement (Medi-Gap) Payor _______________________________________________________ Phone # ____-____-____ Policy # ________________________________ Billing Address (if not on card) ___________________________________ Medi-Gap Plan Type ___________________________________________ If not Medi-Gap, does the plan pay Medicare A or B coinsurance _____________________________________ Medicare Information Medicare Number: ________________________________________ Medicare A Active Date _____________________ Medicare B Active Date ___________________________ MSP Coverage □Yes □No

Open Hospice Election □Yes □No

Medicare Advantage Coverage □Yes □No *If yes, complete Insurance Primary Section Med A – Days Available ________ Med B – Therapy Used ________________________ Qualifying Hospital Stay

□Yes □No

Date span of qualifying hospital stay ____________________________ Medicaid

Medicaid Number: __________________________________ Active Coverage □Yes □No All applicable paperwork submitted to state □Yes □No Monthly Patient Liability Amount $ _________________

Attach front and back copies of Medicare, Medicaid and insurance cards and eligibility screenshots if not scanned electronically. Disclaimer: Use of this form is no guarantee of payment or that all payor requirements have been met.