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Xofigo Insurance Benefit Verification Request Form - il pparx 2026

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4.8 out of 5

119 votes

The document is an Insurance Benefit Verification Request Form specifically for referring providers to request insurance benefit verification services for Xofigo® (radium Ra 223 dichloride) Injection. It outlines the process for submitting the form, including necessary patient and provider information, and details on how Xofigo Access Services will verify insurance benefits and communicate results. Additionally, it includes a Patient Authorization section for the use and disclosure of protected health information (PHI) related to treatment and insurance eligibility.

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Click ‘Get Form’ to open the Xofigo Insurance Benefit Verification Request Form in the editor.
Begin by filling out the Referring Provider Information section. Include your name, specialty, NPI#, Tax ID#, practice name, and contact details.
Next, complete the Patient Information section. Provide the patient's name, date of birth, address, email, scheduled treatment date/time, and phone number.
In the Patient Insurance Information section, input details for primary and secondary insurance including policy numbers and contact numbers.
Review the Physician Declaration carefully. Ensure all information is accurate before signing and dating this section.
Finally, navigate to the Patient Authorization section. The patient or their representative must sign and date this authorization for processing.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (119 Votes)

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