Insurance Navigation Intake Form

TDBI Hair Solutions - Insurance Navigation Form

IMPORTANT INFORMATION

All fields marked with * are required. Please have your insurance card and doctor's prescription available.

This form is for information gathering only. We will contact you to discuss your benefits.

Payment for services is due at the time of service. We provide documentation for you to submit to your insurance for reimbursement.

We cannot guarantee insurance coverage or reimbursement amounts.

1. PATIENT INFORMATION

Full Legal Name

Date of Birth

Phone Number

Email Address

2. INSURANCE INFORMATION

Insurance Company

Member ID Number

Group Number

Insurance Phone

3. MEDICAL INFORMATION

Primary Diagnosis

Prescribing Physician

Treatments (check all that apply):

Chemotherapy

Radiation Therapy

Autoimmune Treatment

None

4. SERVICE REQUEST & AUTHORIZATION

Preferred Location

Requested Service Date

PATIENT AUTHORIZATION

I authorize TDBI Hair Replacement Solutions to verify insurance benefits for cranial prosthesis (HCPCS code A9282) and prepare documentation. I understand I am responsible for payment at the time of service and will seek reimbursement from my insurance company.

No signature saved

Date of Signature

TDBI HAIR REPLACEMENT SOLUTIONS

SERVICE 5: INSURANCE NAVIGATION FORM

IMPORTANT INFORMATION

1. PATIENT INFORMATION

2. INSURANCE INFORMATION

3. MEDICAL INFORMATION

4. SERVICE REQUEST & AUTHORIZATION

Email Us

Call Us

Privacy Policy

Headquarters

Hour