Patient Registration Form (PRF)

I certify that the information on this form is correct to the best of my knowledge. By signing this form, I authorize Larsen Billing Service (LBS) to verify my primary insurance benefits and charge me the fee of $20. I authorize secondary insurance benefits to be verified for an additional fee of $10 if necessary.   Read More...

Once this form has been completed, LBS will begin the process of verifying your benefits. We will also pursue obtaining pre-authorization and in-network exception (if possible). We will send a copy of the verification information to the email address listed above on the Patient Registration Form and to your provider. Please note that Verification is not confirmation that the insurance company will pay what is stated when verifications were obtained. The insurance company has the right to make a final ruling on each claim submitted according to their latest policies and procedures. LBS is not responsible for deviations from the insurance coverage described within the VOB form, nor for incorrect information given by health plan representatives. Some insurance companies may be difficult to obtain benefits from; if the benefits call exceeds two hours, we will contact you for assistance in obtaining a complete Verification of Benefits. LBS will send the completed Verification form to both the patient and the provider from an email address and system that is appropriately encrypted according to HIPAA/HITECH regulations, but is not responsible for any breach that may occur due to the message being received by an unsecure email address. I understand that the purchase of Verification services does not guarantee that my claims will be submitted and does not create a contract for billing services between myself and LBS. Read Less

I hereby authorize my insurance company to make payment directly to my provider should claims be filed. I give authorization to my provider to release any information necessary to process my benefits or insurance claims to Larsen Billing Service (LBS). I understand the final outcome for my insurance benefits level and the processing of my claims is under the discretion of the insurance company. I will not hold LBS or my provider responsible for the information reported on this verification or the manner in which my claims process.

In some cases insurance claims may deny and require an appeal process. In this circumstance, I authorize LBS to pursue appeals on my behalf. I understand this will be at the discretion of LBS and there is no additional charge for this service. I also understand that it may be necessary for LBS to contact me via e-mail or by telephone if appeals are pursued. (*Please provide your e-mail address in the top portion of this form.)