Insurance Verification Form

Medical Insurance Verification Form
Client Information
The client is*

A New ClientCurrent client; submitting new insurance informationReturning Client; submitting insurance informationOther
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Legal Sex*
Insurance Information
Primary Insurance Company
*If other, please indicate Insurance Company
Policy No*
Group No*
Subscriber's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Subscriber's Relationship to Client*
Subscriber's Relationship to Client*
Legal Sex*
Insurance Subscriber Address is the Same as the Client*

YesNo
Address for Insurance Subscriber

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you covered under another insurance plan? Such as through a partner, spouse, parent, college health insurance, etc?*

YesNoUnknown
Secondary Insurance Company
*If other, please indicate Insurance Company
Policy No
Group No
Secondary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Subscriber's Relationship to Patient
Legal Sex*
Address for Subscriber if different from Client

Street Address

Street Address Line 2

CityState / 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*

Cancelof
Please attach the following document: State ID for Client*

Cancelof
Should be Empty:

Medical Insurance Verification Form