Medical Insurance Verification Form
Client Information
The client is
*
A New Client
Current client; submitting new insurance information
Returning Client; submitting insurance information
Other
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Legal Sex
*
Please Select
Female
Male
Insurance
Information
Primary Insurance Company
Please Select
Aetna
BlueCross and BlueShield
Cigna/Evernorth
Humana
Moda Health
Optum
UMR
United HealthCare
Sana
Other*
*If other, please indicate Insurance Company
Policy No
*
Group No
*
Subscriber's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Subscriber's Relationship to Client
*
Please Select
Self
Spouse/Partner
Child
Other
Subscriber's Relationship to Client
*
Legal Sex
*
Please Select
Female
Male
Insurance Subscriber Address is the Same as the Client
*
Yes
No
Address for Insurance Subscriber
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you covered under another insurance plan? Such as through a partner, spouse, parent, college health insurance, etc?
*
Yes
No
Unknown
Secondary Insurance Company
Please Select
Aetna
BlueCross and BlueShield
Cigna
Humana
Optum
UMR
United HealthCare
Sana
Other*
*If other, please indicate Insurance Company
Policy No
Group No
Secondary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
Legal Sex
*
Please Select
Female
Male
Address for Subscriber if different from Client
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please attach the following documents: 1. Picture of the Front of your Insurance Card 2. Picture of the Back of Your Insurance Card
*
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Please attach the following document: State ID for Client
*
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Submit
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