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Download-Medical-Insurance-Form-Template

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									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: ___________________________

								
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