Medical insurance form templates are used by the insurance companies to issue medical insurances to the customers and clients. This type of template consists of all the information related to the insurance and the individual concerned.
Sample Medical Insurance Form Template
_______________________
[Name of the Insurance Company]
[Company Logo]
_______________________
[Email Address]
[Policy ID Number]: ___________________________________
[Name of agent]: ______________________________________
[Insured’s Name]: _____________________________________
[Effective date of policy]: _______________________________
[Maximum Number of visits per year]: _____________________
Are the following facilities covered? [Manipulation, physical therapy, modalities, medical examination] ________________________________________________________________
Is there a deductible? __________________________________ [Yes / No]
Co – payment or co – insurance: _________________________ [Yes / No]
If yes, then how much: _________________________________________
What is the claims’ address? ___________________________________________________
Secondary Insurance [Details]:
Insured’s Name: ______________________________________
Relation to patient: ____________________________________
Policy Number: _______________________________________
Employer: ___________________________________________
Company Phone: ______________________________________
Financial policy of the company: ________________________________________________
Responsibility of the company: ________________________________________________
Responsibility of the patient: ________________________________________________
Signature of Patient: _____________________________________________
Date: ___________________________
Download Medical Insurance Form Templatee in Word Format