Patient Insurance Information
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For office use only
Lifetime Maximum:_________________ Paid out at: ___________ Deductible:________________
 
Accepts assignment of benefits: Yes ___ No___  Benefits used to date:________ Age Limit:_______
 
Effective Date: ________ Coordination of Benefits: Yes ___ No ___ Cont of TX Form? Yes___ No ___
 
Waiting Period: ____________ How benefits paid out?________________ Payor ID#_____________

Address for Claims:__________________________________________________________________
 
Spoke with whom:______________ Date Confirmed:_______ Staff: __________