Insurance Information for

McKenzie-Willamette Sleep Solutions Center

Your Insurance may require a prior authorization before a Sleep Study can be performed.  If necessary, we would like to begin this process before your initial consultation appointment. Please send this completed form to us in one of three ways:

Mail the completed form to Insurance Verification, 1460 G Street, Springfield, OR 97477.

Fax it to us directly at 541-744-8518.

If time does not permit mailing or faxing the form, please fill out the form and bring it with you to your first appointment.

GENERAL PATIENT INFORMATION

General Patient I nformation

*Last Name                         *First                     Middle                         *Date of Birth            Age

*Street Address                                        City                                                       State, Zip

Mailing Address (if different)                        City                                                       State, Zip

*Home Phone #                                                       Cell Phone #                         Social Security #

Employer                                  Address                          Occupation        Work Phone # (okay to contact?)

*Primary Emergency Contact                Relation                      Address                                        Phone #

Secondary Emergency Contact             Relation                       Address                                   Phone #   INSURANCE INFORMATION   General Patient Information     *Primary Insurance Company                             Policy #                                             *Group #     Address                                                                                                               *Subscriber’s Name                           *Relation toSubscriber                 Subscriber’s Social Security #                                  Secondary Insurance Company                                     Policy#                                           Group #   Address                                                                                                               Subscriber’s Name                            Relation to Subscriber                Subscriber’s Social Security #                 Medicare Questions (leave blank if you don’t have Medicare insurance)   Are you receiving Black Lung benefits?      Y    /    N    Has a government program (such as a research grant) agreed to pay for care at this facility?   Y   /    N   Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for care at this facility?        Y   /    N    Are you entitled to Medicare based on:           AGE           Disability            End Stage Renal Disease (ESRD)    Are you employed?   Y  /   N       If Yes:  Name and Address of your employer _________________________   __________________________________________________________________________________________  If No: Date of Retirement/ Never Employed _________________________                                                      Is your spouse employed?  Y  /   N      If Yes:  Name and Address of employer   ___________________________________________________________________________________________  If No: Date of Retirement/ Never Employed  _________________________    Do you have group health plan (GHP) coverage based on your own, or a spouse’s current employment?   Y   /    N    Insurance Company_____________                 Policy #_______________                 Group #_________________    Does the company employ more than 20 employees?      Y   /    N