Medical Insurance Verification Form
A medical insurance verification form is used whenever an individual applies for a medical claim after undergoing a medical treatment. This form helps a person to get compensation from the medical insurance company and it also helps in verifying the credentials of the person who has applied for the insurance.
Sample Medical Insurance Verification Form:
Policy number: ___________
Medical insurance company: _______________________
Name: First name ___________ Middle name __________ Surname _____________
Father’s name: First name __________ Middle name _________ Surname __________
Permanent address: Street address ____________ City name ____________ State _____________ Zip code _____________
Current address: Street address ____________ City name ____________ State _____________ Zip code _____________
Home contact number: _____________ Mobile number: _______________
Employer’s name: ______________
Employer’s address: Street address ____________ City name ____________ State _____________ Zip code _____________
Work contact number: __________________
I assure that all the information provided by me is true. I authorize my insurance company to give all the required information required by _______________ (name of hospital or medical treatment centre) for the insurance amount claimed.
________________
Signature of the candidate
Dated: ______________
Category: Verification Forms
