MRT Insurance Verification Form

MRT Insurance Verification Form Consultant Name: Physician Signet Diagnostic Corp Ellen Metzger, RD Name & 3555 Fiscal Court, Suite 9 PH: 860-573-4002 Address Riviera Beach, FL 33404 FAX: 860-659-4656 Tax ID#: Phone#: Fax#: Contact At Doctor’s Office: 65-0392284 561-848-7111 561-848-6655 Patient’s Insurance Information Patient’s Name: Patient’s DOB: Patient’s Insurance ID#: Alison Metzger 2-2-1992 Patient’s Phone #: Patient’s Zip Code: Patient’s Relationship To Insured: 860-573-4002 06033 CHILD Insured’s Name: Insured’s DOB:: Insured’s Insurance ID#: Ted Metzger 10-19-1961 Group #: Policy #: Insurance Company Name: Ins. Co. Benefits Phone #: 010187001 XGP 0171M50448 Anthem BCBS HMO 800-843-6096 Insured’s Employer Name: ICD-9 Codes: 493.9 Is The Doctor Contracted with this Insurance Company? Is Doctor PCP or Specialist for this patient? Insurance Provider #:

Insurance Verification Results Date Submitted: Date Verified: Employee Doing Verification: Insurance Rep: Effective Date: 5-11-2011 5-11-2011 Nancy Zamadics-Kenney Herbert 1-1-2010 Claims Mailing Address: P.O. Box 1798, Jacksonville, FL 32231

Does Client Have Out-Of-Network Co-Pay Covered For CPT Code Deductible: Deductible Met: Coverage %: Coverage? (% Or $ Amount) 83516 @ 150 Units? In-Network N/A N/A N/A N/A N/A Coverage Information: Out-Of-Network N/A $500 $0 70% YES**See Below Coverage Information: Is Pre-Authorization Required For Coverage? Pre-Authorization Department Phone number: Preauthorization Number: NO For Patients That Require Preauthorization, Do Not Schedule Blood Draw Prior to Receiving Preauthorization # Contact your LEAP Consultant for clarifications of any information on this form or if you have any questions.

CPT Code 83516 has no limitations or exclusions listed – must be medically necessary.

Covered Out-Of-Network / Unmet High Deductible Notes The patient is covered for the service but has not met their annual deductible. The patient can elect to do the And/Or procedure at the discounted price of $595 payable to Signet Diagnostic by check or any major credit card. Actions For Doctor

Signet Diagnostic Corp. 3555 Fiscal Ct. Suite 9, Riviera Beach, FL 33404 Phone: (561) 848-7111 Disclaimer: Verification of insurance coverage is not necessarily a guarantee of payment Copyright 2004 Signet Diagnostic Corporation Version 5.7