PI/Auto Tools > Insurance Verification Type > PI/Auto Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicBalanced Living ChiropracticCoulee HealthErickson ChiropracticHendricks ChiropracticHome Team ChiropracticHonchel ChiropracticKaizen ChiropracticModern Spine Health (Richard Wilson)Nemitz ChiropracticRestore Spine and Wellness (Mequon)Revive ChiropracticTruhlsen ChiropracticTruhlsen Chiropractic-HendricksWeber ChiropracticWW AppletonWW BeavertonWW BismarckWW BloomingtonWW Burr RidgeWW Eau ClaireWW FitchburgWW Flathead ValleyWW Fort MillWW Grand RapidsWW Grass ValleyWW Green BayWW JacksonvilleWW Lake MaryWW LargoWW LouisvilleWW MariettaWW North PhoenixWW PensacolaWW RaleighWW South JordanWW SpringWW SteubenvilleWW St CloudWW St PetersWW WaukeshaWW Wesley ChapelWW Woodbury (Empower Health)Patient's Auto InsuranceName of Patient's Auto Insurance Does this patient have their own auto insurance with Medpay available to bill to? Yes, patient's account is set for billing to this insurance. Insurance company sends payment to clinic until medpay is maxed out. No Additional comments?Third Party Liability Insurance (At Fault Driver)Name of Third Party Liability Insurance Does this patient have third party liability insurance? Yes No Will we be billing to the third party liability insurance? Yes No Additional InformationSince this patient does not have their own auto insurance (or they do not have medpay available through their own auto insurance), we will be billing to the third party liability insurance. When billing to third party liability insurance, no payment is issued from the insurance company to the clinic until the patient settles their claim with this third party liability insurance.Additional InformationSince this patient has their own auto insurance and medpay is available, we will not be billing to this patient's third party liability insurance.Attorney InformationHas patient retained an attorney? Yes No Name of Attorney Additional InformationWe will work with this attorney to supply them with the statements and records they need as they seek a settlement for this auto claim.NotesDisclaimer When we call on a patient's auto insurance and verify benefits, it is not a guarantee of payment by the insurance company and may vary according to the patient's individual coverage when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient must understand that their insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact benefits.EmailThis field is for validation purposes and should be left unchanged. Δ
