Insurance Information Form

Your consent & understanding of our practices are important to us.

When I need to complete this form: In preparation for my Initial Evaluation appointment, If my Insurance provider has changed, or if my prescribed medications require a Prior Authorization.

Why we need this form: In order to obtain Prior Authorizations for prescribed medications in a timely manner for our patients.

How we use this form: The information provided below is utilized by Dr. Tracey Jones for medication prescribing purposes to complete Prior Authorizations.

Personal Information

Your Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Acknowledgements

By sharing my Insurance information, I understand that it will be utilized by Dr. Jones only for medication prescribing purposes (ie. Prior Authorization).

I understand

I understand that my Insurance Information will not be utilized by the Billing Office and that claims will not be submitted by the office of Dr. Tracey Jones.

I understand

I understand that I am able to submit claims (for out-of-network benefits for possible reimbursement) on my own behalf with a superbill/detailed receipt provided to me by the Billing Office upon request.

Each insurance company varies when it comes to submitting claims (e.g. faxing, emailing, submitting on insurance portal/website, etc.). To see if you qualify for out-of-network benefits and to learn about your Insurance company’s claim submission process, please contact their Member Services by utilizing the Phone # found on the back of your Insurance card.

I understand

Insurance Information

Insurance ID/ Member ID

Insurance Company

Include plan name if applicable e.g. PPO, HMO

Rx BIN #

Name of Pharmacy Benefits Manager (If applicable)

e.g. FutureScripts, Optum RX

Provider Services Phone #

This is usually found on the back of your Insurance card

(###)

###

####

Signature & Date

Digital Signature

By typing my name below, I hereby grant the use of this information for the reasons explained in this form.

First Name

Last Name

Digital Signature - Guardian

Please utitilze this field if you are filling this out on behalf of somebody else. (Please place the patient's name in the field above.) By typing my name below, I hereby grant the use of this information for the reasons explained in this form.

First Name

Last Name

Today's Date

MM

DD

YYYY