Insurance verification form
An insurance verification form collects the policy number, group number, and provider name a patient brings to an appointment so your staff can verify coverage manually before the visit starts. This saves time on the phone with the insurer later and lets you flag coverage gaps before treatment begins. Unlike automated eligibility checks through insurance APIs, this form simply gathers the information your staff needs to call and verify.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
No automatic eligibility lookup — staff verify manually
This form is not connected to any insurer's API. It collects the details your staff needs to call and ask. That keeps the form simple and avoids broken integrations when insurance systems change.
Policy and group number are separate fields
Insurance cards print both a policy ID and a group number. Splitting them into two fields makes it obvious which is which and reduces the risk of transposing them when staff verify.
No card required.
Insurance Verification
Live previewHow to build this form
5 steps in the editor. Nothing here needs a paid plan.
- Add text fields for the patient's full name and date of birth — required so the insurer can look them up.
- Add a required text field for the insurance provider name.
- Add required text fields for policy/member ID and group number — the identifiers that appear on the insurance card.
- Add an optional text field for the subscriber name if it differs from the patient.
- Add an optional textarea for reason for visit, so staff can note what they're verifying coverage for.
Fields in this form
7 fields, using 3 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Patient full name | Short text | Yes |
| Date of birth | Date | Yes |
| Insurance provider | Short text | Yes |
| Policy/member ID | Short text | Yes |
| Group number | Short text | Optional |
| Subscriber name (if different from patient) | Short text | Optional |
| Reason for visit (optional) | Long text | Optional |
What goes wrong with this form
Specific to a insurance verification form, not general advice about forms.
Calling this form "eligibility verification"
That phrase signals automatic eligibility lookup, which this form does not do. Call it insurance information or insurance verification if your staff verify manually.
Making subscriber name required when it matches the patient
Most of the time the subscriber is the patient. Leave that field optional so patients don't type their name twice.
Skipping the provider name field
If you only ask for a policy ID, staff still have to call or text the patient to ask which insurer it is.
Questions about this form
Does this form check coverage in real time?
No. This form collects insurance information only. Your staff verify coverage manually by calling the insurer or checking their portal. Real-time eligibility APIs are complex and break when insurance systems change — this approach is simpler and more reliable.
What if a patient doesn't have insurance?
Make the insurance fields optional, or add a checkbox "I do not have insurance" so they can submit without a provider name or policy number.
Can I export the data?
Yes. Every response exports to CSV in one click — one row per patient, with columns for name, insurance provider, policy ID, group number and any other fields you add.
Other templates
- Patient intake formInsurance provider and ID as their own fields, so registering doesn't start with a phone call.
- Medical HistoryCollect a new patient's medical background before the first appointment.
- Dental Patient IntakeCollect a new dental patient's background, last visit date and chief complaint before their appointment.