Insurance Verification Form

Please fill out the information below so we can verify your insurance. Do not leave any blank spaces. If the question does not apply to you, please put an X in the box.

 

QUESTIONS?

If you're having issues submitting or have a general question. Feel free to call us at (888) 388-9929.

 

GENERAL INFORMATION

Who is this for?*

Client Full Name*

Client date of birth*

Subscriber Full Name

Subscriber Date of Birth

Phone Number*

Email*

INSURANCE INFORMATION

Insurance Provider*

Insurance Provider Phone Number (on back of card)*

Type of Plan*

Insurance ID Number*

Group ID Number*

ADDITIONAL INFORMATION

Have you been to treatment before?

Brief description of your problem

How did you hear about us?*

Comments

Please leave this field empty.