Ins. Verification

Insurance Verification Form

* Indicates required field

Patient Name *

First

Last

Patient ID *

Number *

Insurance *

D O B *

PCP *

Ins. Ph. Num. *

Gender *

PCP Number *

Policy Type *

Social Security *

1st Study? *

Policy ID *

Phone Number *

Date Last Time *

Policy Group *

Sleep Study Requested *

Policy Start Date *

Policy End Date *

In-Network Benefits

Co_Pay $ *

Deductible $ *

Is It Met? *

Met *

Remaining *

Co-Ins *

OOP $ *

OOP Met $ *

OOP Remaining $ *

Requires Pre-Authorization? *

Notes: *

Reference Number *

Agent Name: *

Out-Network Benefits

Co-Pay $ *

Deductible $ *

Is It Met? *

Met *

Remaining *

Co-Ins *

OOP $ *

OOP Met $ *

OOP Remaining $ *

Requires Pre-Authorization? *

Pre-Authorization Number *

Pre-Authorization Agent: *

Pre-Authorization Valid From-To: *

Verified By: *

Procedure Codes: *

Primary Dx Codes: *

Supporting Dx (With a Primary Dx) *

AISP Insurance References
Gonzalez and Castellanos (TAX ID: 65-0430812 NPI: 1447285606) ; DR Gonzalez (NPI: 1134152051) : DR Castellanos (NPI: 1326077967) : AISP (TAX ID: 52-2413969 NPI: 1093740235)
Next to the insurance’s name please find who they bill under. Split studies, authorization approved for both CPT codes 95810 and 95811is Required. Brenda (305) 824-3244

Medica (AISP)................................................. Commercial, Individual and Medicare Plans
Medicare (AISP)................................................................................................ No Medicaid
Molina Health Plans (AISP)
Preferred Care Partners (AISP)............................................................................... All Plans
Simply Health Plans (AISP)………………………….……..….……………….…..……All Plans
Tricare (AISP)……………………………………………….……………… ……………All Plans
United Health Care (G&C).HMO & PPO (No UHC Medicare Complete or Secure Horizons)
WellCare (AISP)....................................................................................................... All Plans
Other PPO’s.................................................................. Check with AISP prior to scheduling

Aetna (G&C) ................................................................................ EPO, PPO, POS & HMO
AvMed (AISP)............................................................................... PPO, EPO, POS & HMO
BCBS (G&C)....................... PPO, POS & Blue Options (NO HEALTH OPTIONS or HMO)
CarePlus (AISP).................................................................................................... All Plans
Cigna (G&C)..................................................................................... PPO, POS (NO HMO)
HealthSun (AISP)................................................................................................... All Plans
Humana (AISP)............................................... PPO, POS, EPO, HMO (with Authorization)
Leon Medical Centers Health Plan (AISP)............................................................. All Plans

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