Insurance Verification Form

Insurance Verification Form – Rockford, IL

Insurance Verification Form

The following form is to be used collect insurance information from patients that wish to see if their insurance will cover services provided at Circle of Wellness. By submitting this form, you agree to allow the Circle of Wellness billing department to contact your insurance.

For questions call or email the billing department 779-423-1700 or [email protected]

We accept insurances including:

BCBS (PPO’s Only)
QUARTZ
UHC
AETNA
VA
HEALTH ALLIANCE
MEDICARE B & C
UMR
MARKET PLACE PLAN

MOLINA
ALL SAVERS COVENTRY
AARP
MERIDAN (under 20yr)
N IL HEALTH PLAN
HFN
ECOH
THE ALLIANCE

We also accept flexible spending accounts, and auto accident injury claims.

Name

Last Name

Date of Birth

Phone

Address

City

State

Zip

Gender

Martial Status

Referred By

Occupation / Place of Employment

Emergency Contact Name

Emergency Contact Phone

Relationship

Primary Insurance

Name of primary insurance holder:

Date of Birth of Insurance Holder

Employer that insurance is offered through.

Insurance Company Name

Insurance Company Phone Number

Insurance Member ID

Insurance Member Group Number

Secondary Insurance

Name of primary insurance holder:

Date of Birth of Insurance Holder

Employer that insurance is offered through.

Insurance Company Name

Insurance Company Phone Number

Insurance Member ID

Insurance Member Group Number

Important Insurance Information Acknowledgment

I agree that I have read and understand the statements made above pertaining to the billing of my insurance services. I understand that insurance services are billed at a higher rate than cash services rendered under Circle of Wellness.

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Insurance Verification Form