Quote of Benefits Form

Quote of Benefits Form

This Quote of Benefits Form will help us determine what your insurance benefits are and consequently, what you out-of-pocket costs will be. Please fill in the information in Part One. Part Two is for you to fill out as you speak to your insurance provider representative.

Part One

Patient Name:	_______________________________	Date of Birth:	__________
Insured's Name:	_______________________________	Date of Birth:	__________
Insured's Zip Code:	__________	Insured's Employer:	____________________
		Insured's Social Security #:	_____-____-____
Insurance Company Name:	_______________________________	Policy ID #	____________________
Insurance Company Phone Number:	_______________	Policy Group #	____________________

Part Two

Telephone Script to Call Your Insurance Company:

Tell the insurance representative, "Hi, my name is _____ and I am calling to obtain a quote of benefits for my insurance plan. My first question is:

1. Is my insurance policy considered a PPO plan? YES or NO

If NO, unfortunately you will not be able to submit your claims as we are not a part of any HMO's.

If YES, please proceed to Part Three below.

Part Three

For those with Out-Of-Network PPO Plans

Tell the representative, "I would like a quote of benefits for an OUT-OF-NETWORK sick medical office visit with a family practice doctor and labs done in the office."

Today's Date/Time:	___________	I spoke with:	__________
What is my effective date of coverage?	___________	At what percentage are my claims paid?	___________
Do I have a deductible?	__________	If yes, how much is my deductible?	__________
How much of my deductible has been met so far?	___________	When does my deductible renew, calendar or policy year?	__________
What is my maximum out-of-pocket?	__________	Has anything been applied to my out-of-pocket?	___________
What is the percent of coverage for in-office diagnostic lab work?	__________
What is the mailing address for sending claims?	_____________________________________ _____________________________________ _____________________________________

<< Return to New Patient Tour