Auto Insurance Claim Verification – Miller Medical Massage

Once you submit this form we will receive it and contact your carrier directly, please allow us 24-48 business hours to complete this request. Once your claim is verified, you may schedule your first appointment within our office.

Patient's Name *

First

Last

Patient's Date of Birth *

01/01/2023

Patient's Phone Number *

Patient's Email *

Patient's Auto Insurance Company *

Patient's Medpay Claim Number *

What is your Medpay policy limit? (ex: $2k, $5k, $10k, etc.) *

We need this information to try to limit any out of pocket expense for the patient. We try our best to make sure that your expenses are covered by your medpay policy.

Have you had any other care that has utilized your Medpay policy? *

Yes
No
Unsure

Claims Adjuster's Name *

First

Last

Claim Adjuster's Phone Number *

Claim Adjuster's Fax Number

Claim Adjuster's Email

File Upload (Auto Insurance Card)

Click or drag files to this area to upload. You can upload up to 20 files.

Please upload a copy of your auto insurance card, front and back.

File Upload (Massage Referral)

Click or drag files to this area to upload. You can upload up to 20 files.

If our office already has a copy of your massage referral then this step is not necessary. Please confirm that we have a copy of your referral upon submittal so that we may quickly and accurately verify your claim.

File Upload (Any other documents you want to submit)

Click or drag files to this area to upload. You can upload up to 20 files.

Signature

By signing below, you acknowledge that the information provided it accurate and truthful to best of your knowledge. You consent to Miller Medical Massage verifying your auto insurance coverage.