TheraSkin Benefit Verification Request Form - Soluble Systems 2026

1. Click ‘Get Form’ to open the TheraSkin Benefit Verification Request Form in the editor.
2. Begin by filling out the Patient Demographic Information section. Enter the patient's name, Social Security number, address, phone number, and date of birth accurately.
3. In the Patient Wound Information section, select the appropriate wound type from the provided options. If prior authorization is required, indicate 'YES' and ensure to attach clinical records.
4. Complete the Product HCPCS and Application CPT(s) fields as applicable. Make sure to provide accurate diagnosis codes in the ICD-9 Diagnosis Code(s) section.
5. Fill in the Patient Insurance Information by including details for both primary and secondary insurance. Attach a copy of the patient’s insurance card if possible.
6. Provide Physician Information including place of service, physician name, specialty, and contact details. Ensure all fields are filled correctly.
7. Finally, complete the Physician Declaration by signing and dating where indicated to certify that you have received necessary patient authorization.

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