Medical and Insurance Intake Form

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

What is your preferred way of contact?

Referral Source

Diagnosing Provider/Specialist Name and Practice Name:

Diagnosing Provider/Specialist Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Care Physician Name

Primary Care Physician Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you have a documented medical diagnosis from a licensed medical provider that directly relates to your hair loss? You must have a diagnosis from a provider to proceed.

What is your medical diagnosis? (Example: Alopecia, Trichotillomania, melanoma, etc.)

Diagnosis Questions Related to Hair Loss

Rows	Yes	No
Is your hair loss sudden?
Is there a family history of hair loss?
Are you experiencing scalp itching or pain?
Do you have any chronic illnesses?

Current Medical Conditions

Allergies

Current Medications

Have you had any other forms of treatments for the hair loss? If yes; please list the previous treatments you have had.

Upload any documentation and prescription information. If you have a letter of medical necessity from a provider please provide that letter.

Please upload clear photographs of the area(s) affected by hair loss. These photographs may be used as supporting documentation for insurance verification, prior authorization, or claim submission when applicable.

Medical Insurance Provider

Insurance Policy Number

Insurance Group Number

Name of Insured (if different from patient)

Relationship to Patient

Date of birth of the insured (if different from the patient)

Date

Upload Front of Insurance Card

Upload Back of Insurance Card

Do you authorize KAM Hair Loss Services to verify your insurance benefits, communicate with your insurance carrier, and prepare and submit applicable claim documentation on your behalf?

I certify that the insurance information provided in this form is accurate and current to the best of my knowledge. I understand that I am responsible for notifying KAM Hair Loss Services of any changes to my insurance coverage or policy information.

Who is your hairstylist? What is their first and last name?

What is your Stylists phone number? Include area code

Insurance Benefits Verification and Claim Preparation Fee – $97

A one-time $97 administrative fee is required for KAM Hair Loss Services to verify your insurance benefits and prepare and complete your insurance claim.

This introductory rate is available through September 30, 2026. Beginning October 1, 2026, the Insurance Benefits Verification and Claim Preparation fee will increase to $197.

Important Information
Non-Refundable Fee: The $97 fee is non-refundable, including in situations where your insurance plan does not provide benefits or coverage for a cranial prosthesis. The fee covers the time and administrative work required to contact your insurance provider, verify available benefits, and prepare the necessary claim documentation regardless of the outcome.
Verification Does Not Guarantee Coverage: Insurance verification is not a guarantee of coverage, reimbursement, prior authorization, claim approval, or payment. All coverage and payment decisions are made solely by your insurance carrier and are subject to the terms of your individual policy, including any exclusions, deductibles, coinsurance, limitations, or other requirements.
Information May Change: Verification results are based on the information provided by your insurance company at the time of our inquiry. Insurance benefits and coverage determinations may change and are ultimately determined by your insurance carrier.
Option to Contact Your Insurance First: If you would prefer to determine whether your insurance plan may offer benefits for a cranial prosthesis before paying the verification fee, you are welcome to contact your insurance company directly. Upon request, KAM Hair Loss Services can provide you with a list of suggested questions to ask your insurance representative.
Hair Installation and Stylist Payment: Your hair installation and related services are arranged directly with your stylist and are paid at the stylist's established rate for the complete service. The insurance claim will be prepared based on the total amount you actually paid your stylist for the applicable service.
Acknowledgment
By signing below, you acknowledge and agree that the $97 Insurance Benefits Verification and Claim Preparation fee is non-refundable. You also understand that KAM Hair Loss Services cannot guarantee insurance coverage, prior authorization, claim approval, reimbursement, or payment.

I understand that I am financially responsible for the cost of services and products provided by my hairstylist. I understand that insurance reimbursement, if available, is determined solely by my insurance carrier. I am responsible for any costs not covered or reimbursed by insurance.

Signature

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$97.00 Quantity

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Payment Methods

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Choose from one of the PayPal options to make your payment.

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Medical and Insurance Intake Form

Patient Information

Specialist Information

Medical Information

Insurance Information

Stylist Information

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Medical and Insurance Intake Form

Patient Information

Specialist Information

Medical Information

Insurance Information

Stylist Information

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