Name:
Policy:
Claim:
Group:
Plan:
Verify:
Effective:
Stop:
Phone:
Comments:
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Insured
Insured Name:
Pt Relation to Insured:
Employer
Insured Employer:
Employement Status:
Preferred Providers
Home Care Agency:
DME Company:
Guarantor
Relationship to Patient:
Name:
SSN:
Address Line 1:
Gender:
Address Line 2:
Home Phone:
City/State/Zip:
Coverage
Contact:
HH Benefits?
Max Episode
Phone:
% Coverage:
Max Episode Days:
Date:
Effective Date:
Max Lifetime
Copay
Deductible
Max OOP
Deductible Met?
Remaining
Restrictions:
No Fault Benefits?
Compensation?
Exclusionary Clauses:
Billing Documentation:
Private Duty Coverage:
PD Billing Documentation:
Services
Services Covered:
Nursing
Shift Nursing # hrs:
HH Aide # hrs-A.M.:
HH Aide # hrs-P.M.:
Shift Nursing Level:
Case Manager
Case Managed?
Case Manager:
Phone:
Fax:
Billing Changes
Submission Error?
Eligibility Change?
Private insurance does NOT cover services?
MCR Denial - Service:
Date Effective:
Last Billable Visit Date:
Other Billing Change:
Bill Rates