Get and Sign HEALTHSOUTH PATIENT DATA Amp INSURANCE VERIFICATION SHEET Form

Phone - - ext of Visits Ordered Auth. GERIL THERAPY Rep. EXPLANATION OF BENEFITS Policy Effective Date / / Deductible Amt. of Deductible Met Out of Pocket Patient Percentage or Co-pay Code C Max Visits Allowed Max Amount Allowed Primary Care Referral Y or Benefits Exhausted Y or Pre-cert Req Y or N MANAGED CARE Will Network be used for Repricing Y or HMO PPO POS IPA MCARE HMO If so Network Co. Expiration Date / / Diagnosis Code Service Class Fax - - BILLING ADDRESS address where claim should...