Competency (VIII.P.1; VIII.P.2)
Instructions: Review the content on the patient registration form on page 59 of your workbook, and
complete the insurance verification form below using the information found on the patient registration form
and the insurance card found on the bottom of page 59 in your workbook. This is a competency
assessment.
Accuracy: Student must achieve 80% or higher. Please refer to the competency assessment sheet for
further instruction.
Insurance Eligibility Verification
Patient’s Last Name, First Name, Middle Initial: ______________________________________________________
Patient’s DOB: _________________________________________
Gender: ________ Female ________Male
Insurance Specialist or Office Manager’s Name: ____________________________________________ (Your Name)
Date Verified: ____________________________
Provider Name: _____________________________________
Health Insurance Plan Name: ______________________________________________
Group No: __________________________________________
Health Insurance Policy Number: ___________________________________________
Health Insurance Plan Effective Date: ________________________________________
Insurance Status: ________________________________
Health Insurance Plan Termination Date: _______________________________________
Plan Type (Cycle One): PPO HMO POS Group MC Capitated WC
$________Deductible Amount $________ Amount not Satisfied $____________Copayment Amount
_________Yes __________No (Pre-existing Clause)
Percentage of Reimbursement: _____________________________% Coinsurance
What is plan coverage? ___________ Medical/Prescriptions __________________________
What are the plan requirements? ____________________________________________________________
Explain in detail how you can verify insurance and documentation for a patient?