Healthcare Verification Log

HEALTHCARE VERIFICATION LOG

Use this log to document verification of patient identity, demographic information, insurance eligibility and benefits, authorizations/referrals, and any related communications. Completion of this form indicates the verifier followed facility verification procedures and that the information recorded is true and accurate to the best of their knowledge.

Patient Information

Verification Details

Verification Date:    Time:

Verification Method: In-person Phone Patient Portal Fax Electronic Health Record

Identifying Documents Verified: Government ID Insurance Card Photo on File Other:

Insurance Information

Eligibility Status: Active Pending Terminated Unknown

Prior Authorization Required: Yes No

Authorizations / Referrals

Referral Required: Yes No    Referral Obtained: Yes No

Benefits Verified

Covered Services Verified: Inpatient Outpatient Surgery Imaging Lab Medications

Authorization & Patient Acknowledgment

By signing below, the patient authorizes the facility and its agents to obtain and verify insurance and benefit information, to communicate with insurers and referring providers as necessary for claims, authorizations, and referrals, and to release medical and billing information reasonably necessary for those purposes. Verification recorded on this log does not constitute a guarantee of payment by the insurer. The patient acknowledges financial responsibility for services not covered or denied by the insurer.

Authorization Expiration Date:

I acknowledge receipt of the facility's privacy practices and consent to release of necessary information to insurers and their agents for claims and prior authorizations.

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