Insurance Worksheet

Date:_________________________

Policy Holder’s Name:___________________________________________________________

Policy Holder’s Address:_________________________________________________________

Home Phone:_____________________________

Business Phone:___________________________

Date of Birth:_______________________________________________________

Place of Employment:______________________________________________________

Group Plan Number:___________________________

Policy Number_____________________

ID Number:_________________________________________________________

Insurance Company:__________________________________________________

Insurance Company’s Phone Number:____________________________________

Phone insurance company and ask for Group Health Claims Department.

Is there any coverage for: a) Custom made orthopedic shoes? Yes  No

How much is covered?________________________ Number of pairs?_________________

Frequency? Every calendar year  Every anniversary year

Who needs to prescribe it? Family physician  Orthopedic Surgeon Podiatrist

Chiropodist Other___________________________________________________

Does prescriber need to put diagnosis on the prescription? Yes No

Is there a deductible? Yes No How much________________________

Is there any coverage for: b) Custom made Orthotics? Yes No

How much is covered?________________________

Number of pairs?__________________

Frequency? Every calendar year    Every anniversary year

Who needs to prescribe it? Family physician   Orthopedic Surgeon    Podiatrist

Chiropodist Other___________________________________________________

Does prescriber need to put diagnosis on the prescription? Yes   No

Is there a deductible? Yes   No   How much________________________

Is a biomechanical report required?  Yes   No