Three Peaks Medical Management, LLC

Insurance Verification Information

Please fill out all of the information below and either fax it to Hillary Olsen at fax # 866-299-7386, or email it to Colleen Amsbury at yoga2colleen@yahoo.com. We will verify your insurance within 1-2 business days, and Colleen will contact you.

 

Patient Name: ___________________________________________________________

 

Primary Phone:__________________________________________________________

(# needs to be what the insurance co. has on file)

 

Address:________________________________________________________________

 

________________________________________________________________________          

 

Date of Birth:                              ________/________/_____________

                                                   (month/day/year)

 

Social Security #: ________________________________________________________

 

Insured’s Name:_________________________________________________________

 

Insured’s SS #:__________________________________________________________

(only fill in the above two if you are under someone else’s plan, i.e. spouse, parent, etc.)

 

Policy No/ Id #:__________________________________________________________

 

_______________________________________________________________________  

 

Group/Member #: _______________________________________________________

 

_______________________________________________________________________  

 

(Please identify every # which appears on ins. card.  This will help expedite the process.)

 

Provider:_______________________________________________________________

(insurance co)

 

Provider phone #:________________________________________________________

 

Address for claims:_______________________________________________________

 

________________________________________________________________________ 

Thank you for your time.

Please call Colleen if you have any questions about this form: 303.532.6808