Insurance Verification

Insurance Verification

Doctor

Williston

C A Initials

Verified on

Patient #

22534

Computer #

7153

Case type

Patient Name

Mr. Michael West

D O B

7/5/1977

Insured’s name

Self

D O B

Relationship

Self

Since (Date)

Injured / ill since

Employer

Target

Phone

8042231451

Address

11105 West Broad Street

Supervisor

Jeffery Richards

City

Glen Allen

State

VA

Zip

23623

Note

Insurance Company

Aetna

Phone

8043308340

Address

9030 Stony Point Pkwy

Insured’s ID

City

Richmond

State

VA

Zip

23225

Group #

145671

Contact

Mr. George

Title

Claims Assoc

Phone

8043308340

Claim #

49349-399-39A

Notes

PPO

Primary or Secondary insurance

Aetna, no secondary

Diagnosis

Allergic contact dermatitis

Treatment prescribed

triamcinolone acetonide topical ointment; follow up two weeks

Policy effective from

Deductible amount per year

Deductible met?

Max payment for initial visit

Max payment covered per visit

Max ceiling for X-ray and other diagnostics

Max number of visits covered per year

Items expressly not covered

Items requiring specific tests & confirmation

Other notes and comments