Insurance Verification Form - Cobb Wellness and Aesthetics

Name: *

IT IS VERY IMPORTANT THAT YOU CONTACT YOUR INSURANCE COMPANY TO DETERMINE THE BEST WAY TO GET YOU LABS PERFORMED. WE DO NOT WANT YOU TO END UP WITH A HIGE LAB BILL. We suggest that you call more than once and document who you spoke to regarding lab coverage.

Depending on your insurance, your labs may be partially covered. If you have PPO coverage, the insurance companies may pay for your labs if you met your deductible and then it will be at a certain percentage. However, you need to find this out if this is the case and if there is a designated lab the specimen must go to. Unfortunately, we cannot guarantee coverage by your insurance plan. This is why we have ALL patients fill this out. Please sign agreeing you understand this.

Signature *

1. Do I have coverage for labs or X-Rays ordered by an out-of-network doctor?

2. If so, do I have an out of network deductible that needs to be met first?

3. How much is my deductible?

4. Has the deductible been met? If not, how much is left to pay?

5. What percentage of the coverage free remains my responsibility?

6. If I have my labs drawn from an out-of-network doctor, but am sending it to my preferred lab, is that considered in network or out of network?

What lab must my test be ran at?

Quest
LabCorp

My lab fees will be: *

Self Pay
Insurance

If you choose to use your health insurance, fees vary from plan to plan. We CAN NOT guarantee that you will receive full coverage for your lab testing. It is very important for you to contact your insurnace company and determine if you have coverage and which lab has been designated for you. Please gign below to indicate your understanding..

Signature *

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