Verification of Benefits

We protect the confidentiality of all communications with our office. Your privacy is our utmost concern. Should you need to share additional information, please call our office.

To ensure your privacy when transmitting your information, this is a secure form.

I have reviewed the privacy notice for HMS-Midwest, LLC and by submitting information to HMS-Midwest, LLC, I hereby authorize HMS-Midwest,LLC to contact my insurance company or managed care company on my behalf to verify benefits/coverage, prior to seeing the provider indicated below.

I understand the HMS-Midwest, LLC cannot guarantee benefits or payment to any provider. HMS-Midwest, LLC is only acting as a third party to assist with obtaining information and will share only the exact information as it has been given to HMS-Midwest, LLC.

	I accept
	I do not accept

By not accepting, your information will not be submitted to HMS-Midwest, LLC for verification purposes. Pre-authorizations for services must be obtained by the provider and/or the patient.

Items in red are required

Name of Provider to be Seen:

Name of Insured:

Date of Birth of Insured:

(ex: 05/22/2005)

Name of Patient:

Date of Birth of Patient:

(ex: 05/22/2005)

Address of Patient:

Insured Id, Certificate or Policy Number:

Name of Insurance Company:

Phone Number for Benefits As listed on Insurance Card:

(ex: 1-800-555-5555)

Reason for Visit: (100 characters max)

How should we notify you of our findings? (Please select one of the following)

Phone:

(ex: 1-800-555-5555)

Can we leave a message?

	Yes
	No

Email:

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Serving Providers in Michigan, Indiana, Illinois, Wisconsin, Ohio, New York, and Florida	Phone: 219.926.8320 info@practicemanagers.com

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