Insurance Verification

Step 1 of 3

Patient Information
Facility Name*
Contact Name*
First Last
Contact Email*
Patient Name*
First Last
Patient Phone
Patient Email
Patient Last Four SSN
Patient Date of Birth*
Date Format: MM slash DD slash YYYY

Primary Insured Information
Primary Insured Full Name*
First Last
Primary Insured Last Four SSN
Primary Insured DOB*
Date Format: MM slash DD slash YYYY
Relationship to Patient
Primary Insured Phone Number
Employer Name

INSURANCE COMPANY INFORMATION
Insurance Provider Name*
Insurance ID Number*
Insurance Group Number*
Insurance Company Phone #*
Insurance Type*
Captcha

A quote of benefits does not guarantee payment. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time the claim is received. PRRS, Inc. represents the information provided is based on the benefits quoted at the time of request and holds no liability for admission determination and/or payment guarantee based on this information. By submitting this verification form you acknowledge and agree to the above disclaimer.

Step 1 of 3

Patient Information

Primary Insured Information

INSURANCE COMPANY INFORMATION