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Medicaid / Insurance Eligibility Verification

Verify insurance coverage and authorized services for a resident.

Kura Solution

Appendix Y — Medicaid / Insurance Eligibility Verification

Verify insurance coverage and authorized services for a resident.

Resident

Resident Name *

Date of Birth *

Medicaid / Insurance ID

Coverage

Insurance Provider

Plan Type

MedicaidCommercialNone

Coverage Verified By

Date

Authorized Services

Authorization Number (if applicable)

Expiration Date

Staff Signature

Staff Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Staff Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.