Insurance Forms

Please provide the neccessary items listed below in order for us to file your insurance claim:

1. Copy of your insurance card. (Front & Back)

2. Your doctor's prescription
How do I get a doctors prescription?

3. Completion of the Patient Registartion form below.

Patient Registration

4. Fax your insurance card and doctor's prescription to this fax number:

FAX: (434) 792-1605

Wigs Unlimited Patient Registration

Patient Information

Last Name

First Name

Middle Initial

Phone Number

Cell Number

Work Number

E-Mail Address

Birth Date

Sex

Male
Female

Sex :: Choose Sex

Address

City

State

Zip Code

Medical Information

Condition or Type of Cancer (example: breast,lung,etc.)

Insurance Informaiton

Policy Holder's Name

Relation to Member

Member ID Number

Co-Payment / Co-Insurance Amount

Primary Insurance Company

Birth Date of Policy Holder

Effective Date

Policy Holder's Employer

Employer Plan?

Yes
No

Identification Policy Number

Insurance Address

Insurance Network

Group Number

Insurance Phone Number for Eligibility Verification

Please Check for verification of electronic signature

My Signature

Please Type Name on Signature

I certify that the information I have reported above is correct and that as the patient I have read, understand and fully accept the Conditions of Registration as stated on the bottom of this document.

YES

CONDITIONS OF REGISTRATION The Practice Wigs Unlimited and/or its employees, agents or assignees will hereafter be referred to as “The Practice”. Authorization & Assignment of Insurance Benefits I do hereby authorize The Practice to apply for benefits for services rendered to myself or others covered under my insurance plan under any health insurance policies/programs providing benefits and do hereby also assign and authorize payment of benefits from my (our) insurance company to The Practice (including benefits payable under Title XVIII of the Social Security Act and/or any other government agency.) I irrevocably authorize all such payments to The Practice. I authorize The Practice to contact the employer or insurance company regarding insurance information, existence of insurance and coverage of my (our) benefits. Financial Agreement I agree that payment in full is due at the time of treatment. I the undersigned (jointly and severally if more than one) further agree that I am legally obligated and responsible and do hereby guarantee payment for all charges incurred. The Practice will file for insurance benefits and accept payments per The Practice’s contractual agreements with the insurance company. Any questions or disputes concerning insurance coverage or payment of benefits is a matter between the insurance subscriber/policyholder and the insurance company. Any assistance in this matter granted by The Practice is given strictly as a courtesy and implies no responsibility on The Practice’s part for filing, follow through or conformation. Should any balances arise due to insurance co-payments, co-insurance, deductibles, termination of coverage, non-payment at time of service and/or any other reason I agree to pay all charges within 30 days of services rendered. I agree that if for any reason a check is returned on my account I will be responsible for a $25.00 returned check fee in addition to the original fees for services. Interest of one and one-half percent per month, eighteen percent per annum, will be charged on all accounts over 30 days. If the balance is not paid within the 30 days or if agreed upon payment arrangements on my (our) account are not made, I authorize The Practice to retain the services of an attorney and/or collection agency to assist with the collection of any outstanding balance and to notify the credit bureaus of my (our) delinquencies. I understand that this will affect my (our) credit rating. If this account is placed for collection, I agree to pay one-third of the unpaid principal and interest as an attorney fee, plus court costs and interest in the amount of one and one-half percent per month, beginning 30 days after the monies have become due or expenses have been incurred. Any expenses incurred by such collection actions, including maximum allowed interest, shall become an additional liability for which I (we) assume full responsibility. Copy of Signature I permit a copy of this authorization and signature to be used in place of this original on all insurance claim submissions and for the release of any medical records and/or other records and information, as stated herein, whether manual, electronic or telephonic. Certification I certify that the information I have reported with regard to my (our) insurance coverage is correct and that the above be honored by my (our) insurance carriers. This certification will also apply to application for benefits under Title XVIII of the Social Security Act and/or any other governmental agency, if applicable. I also certify that I have read the forgoing and understand and fully accept the terms therein.