Insurance Verification Form

Please allow 48 hours for our biller to check your coverage.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Email

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reason for Visit

Chief complaint.

Insurance Provider

Insurance Provider Phone Number

(###)

###

####

Member ID Number on Your Card

Include any letters.

Are You the Policy Holder on the Account?

If not, please indicate the name, gender, and date of birth of the policy holder, and their relationship to you.

Do you have a Secondary Insurance Plan?

If so, please provide the Insurance Carrier and Member ID number for that policy.

How Did You Hear About Us?

Disclaimer

Information on this site is provided for informational purposes and is not meant to substitute for advice by your own physician or other medical professionals. You should not use the information contained here for diagnosing a health problem or disease, or for prescribing any medication. If you have or suspect that you have a medical problem, promptly call your health care provider. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.

Insurance Verification Form

Disclaimer

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