Patient Insurance Benefit Verification Form

INSTRUCTIONS

Option 1: Complete all REQUIRED sections below and submit the form.

Option 2: Fill out the PDF version of this form and email to vob@bmgl.com.

 

If a prior authorization or pre-determination is required by the patient's insurance plan, we will ask you for additional information such as clinical notes and a letter of medical necessity. Please allow one business day for a response from a dedicated billing representative. If you do not receive a timely response, please notify the billing manager at vob@bmgl.com.

 




PATIENT INFORMATION
Patient Name *
Patient Date of Birth (mm/dd/yyyy) *
Patient Sex *
Patient Address *
Patient City *
Patient State *
Patient Zip *



PHYSICIAN / COUNSELOR INFORMATION
Ordering Provider *
Ordering Provider NPI *
Ordering Provider Email *
Ordering Provider Phone *
Ordering Provider Address *



GENETIC TEST INFORMATION
Specify All Tests ordered - Provided Test Code(s) and Test Name(s) *
Specify all applicable ICD-10 codes with Diagnosis *



PATIENT INSURANCE INFORMATION
Patient Insurance Policyholder Name *
Relationship to Patient *
Policy Number *
Group Number
Authorization Number
Payor *
Payor Address
Payor City
Payor State
Payor Zip