Request for Benefit Information Form
Physicians must use this form when requesting assistance with insurance verifications,a prior authorizations, and denied or underpaid claims for a specific patient. This form must be completed in its entirety in order for your request to be processed. Following is the information you will need in order to complete the form:
| Provider Information |
Patient and Insurance Information |
- Provider Name
- Physician Specialty
- Practice/Group Name
- Address
- National Provider Identifier
- Tax Identification Number (mandatory field)
- Provider Number
- Office Contact Name
- Phone Number
- FAX Number
|
- Patient Name
- Patient Address
- Date of Birth
- Subscriber ID Number
- Insurance Company Name
- Insurance Company Address
- Insurance Telephone Number
- Subscriber ID Number
- Patient's Plan Name
- Patient Group Name and Number
|
Be sure to include the date of service and diagnostic information (if applicable) for each claim.
Please remember to sign the form to indicate that your practice has obtained written authorization from the patient to provide the Merck Vaccine Reimbursement Support Center with the information you will be providing on the Request for Benefit Information form, and for the purposes described in the form, and has provided all notices necessary to comply with all federal and state laws and regulations relating in any way to medical and/or health privacy, including but not limited to the HIPAA Privacy Rule, codified at 45 C.F.R. Parts 160 and 164, as amended from time to time.
aIn most instances we have determined that some level of reimbursement was available for Merck's vaccine products; therefore, we are now limiting the number of insurance verification cases that we will research to five (5) for each location of a health care practice per month. A facility location will be tracked by its tax ID number and address.
Download the Request for Benefit Information Form 
Download the Insurance Verification Checklist