Back to insurance verification Insurance premium verification form Premium Verification 1Patient Identification2Premium Verification3Terms & Conditions Are you a patient?(Required) Yes No What is your relationship to the patient?(Required) I’m a family member or caregiver I work in a healthcare provider’s office I work in a pharmacy Other First name(Required) Last name(Required) Email address(Required) Phone number(Required)Fill out the following information so we can verify your patient’s identity:Patient's first name(Required) Patient's last name(Required) Patient's email address(Required) Patient's phone number(Required)Date of birth(Required) MM slash DD slash YYYY Patient PAN member ID Does this all look correct? Please provide us more information about your insurance belowInsurance name(Required) Insurance member ID Are you the policy holder?(Required) Yes No Number of dependents(Required)Premium amount:Premium term(Required)MonthlyQuarterlyAnnuallyPremium amount(Required) Select the document(s) that you are submitting from the following: Insurance card Social Security Administration benefit verification letter Paystub(s) for one whole month Insurance statement COBRA coupons Insurance statement / bill from educational institutions Other Other document type Insurance documents(Required) Drop files here or Select files Accepted file types: pdf, png, jpg, jpeg, gif, doc, docx, Max. file size: 10 MB. Does this all look correct? Review and consent to our terms & conditions Read this carefully before you submit your reported premium insurance information through the form. By submitting information to the PAN Foundation and clicking “I agree,” you’re confirming that you have read, understand, and agree to the PAN Foundation’s terms and conditions as follows: You attest and certify under penalty of law that the reported premium insurance information is complete and accurate. You acknowledge and understand that any false or incomplete information that you provide in your application or through this form could harm the PAN Foundation, including its reputation and tax-exemption status. It could also constitute fraud for which you may be legally liable. You acknowledge and understand that if the PAN Foundation provides you with assistance and then becomes aware of any inaccurate information or fraudulent activity related to your application or the provided assistance, PAN will terminate your grant and may recoup the provided amount. Terms and Conditions(Required) I agree