Medical and Insurance Intake Form

Medical and Insurance Intake Form
Please complete this confidential form to help us better understand your needs and provide you with the best possible service. All information provided will be kept confidential and handled in accordance with applicable HIPAA privacy and security standards. Please Note: To proceed with the insurance review and claim process, documentation of a qualifying diagnosis from a licensed and qualified medical provider is required.
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 Code
What is your preferred way of contact?
Preferred Contact Time Window
Emergency Contact Name and Relationship
Referral Source
Specialist Information
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.
Medical Information
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.)
Date of diagnosis or onset hair loss:

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?

Severity / Extent of Hair Loss
Current Medical Conditions
Allergies (and/or sensitivity to adhesives, tapes, or bonding products)
Current Medications
Have you had any other forms of treatments for the hair loss? If yes; please list the previous treatments you have had.
When Did Hair Loss Start?
Upload any documentation and prescription information. If you have a letter of medical necessity from a provider please provide that letter.

Cancelof
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.

Cancelof
Insurance Information
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)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload Front of Insurance Card

Cancelof
Upload Back of Insurance Card

Cancelof
Secondary Insurance Information, If any:
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.
Stylist Information
Who is your Elevate Verified hairstylist? What is their first and last name?
What is your Stylists phone number? Include area code
What is your Stylist business name and address?
Where did you find your Elevate Stylist?
Expected Date of Service: (If you do not have a date scheduled for your installation, please apply the date your are submitting this form)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If this is a prior installation- Upload for the itemized paid receipt and any documentation of the service provider for your cranial prosthesis.

Cancelof
Authorizations and Acknowledgement
Insurance Benefits Verification and Claim Preparation Fee – $197

A one-time $197 administrative fee is required for KAM Hair Loss Services to verify your insurance benefits and prepare and complete your insurance claim.

This is an introductory rate, currently available to all clients who submit this form. It is a one-time fee. You will not be charged again for the verification and claim preparation covered by this submission.

Important Information

Non-Refundable Fee: The $197 fee is non-refundable, even if 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 does not guarantee coverage, reimbursement, prior authorization, claim approval, or payment. All coverage and payment decisions are made solely by your insurance carrier. They depend on 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 your insurance company provides at the time of our inquiry. Insurance benefits and coverage decisions may change and are ultimately made by your insurance carrier.

Option to Contact Your Insurance First: You are welcome to contact your insurance company directly before paying the verification fee, to see whether your plan may offer benefits for a cranial prosthesis. On request, KAM Hair Loss Services can give you a list of suggested questions to ask your insurance representative.

Hair Installation and Stylist Payment: You arrange your hair installation and related services directly with your stylist, and you pay the stylist’s established rate for the complete service. The insurance claim will be based on the total amount you actually paid your stylist for the applicable service.

Acknowledgment

By signing below, I acknowledge and agree that the $197 Insurance Benefits Verification and Claim Preparation fee is a one-time, non-refundable fee. I also understand that KAM Hair Loss Services cannot guarantee insurance coverage, prior authorization, claim approval, reimbursement, or payment.
Authorization to contact the diagnosing provider
Consent to text and email
Signature
Payment
My Products
prevnext( X )
Insurance Verification

$197.00 Quantity

Total

$0.00
Payment Methods

Fastlane Checkout

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

Contact Info

Payment Info
Should be Empty:

Medical and Insurance Intake Form

Patient Information

Specialist Information

Medical Information

Insurance Information

Stylist Information

Authorizations and Acknowledgement

Payment

My Products*

Payment Methods

My Products