TELEPHONE VERIFICATION
Name: Patient Identifier Number:
Application Number: Eligibility Center:
Interviewer: Date:
Your _______________________________________________________________________________________________
We have made the telephone verification below to complete the certification process.
Information verified by:
Title:
Entity name and address:
Phone number:
Date called:
Time called:
Verification detail:
Please mail or drop off copies of written documents used for telephone verification above in 14 days from the date of call. Your case will be cancelled if we do not receive these papers by _______________________________.
If you have any questions, please call me at (713) _________________________________.
________________________________________________________________ _____________________________
Patient’s Signature Date
For Eligibility Center Use Only
Name:
Title:
Date of Approval:
Signature:
