Purpose: The purpose of this form is to obtain your insurance information so that our team may contact your insurance team, and obtain specific insurance eligibility and benefits information for the specific care you requested. If your insurance information changes after this form has been submitted to us, please email us at firstname.lastname@example.org to update your information.
Once we've obtained your eligibility and benefits information, we will forward it to you for your review, along with additional instructions regarding next steps. Eligibility and benefits inquiries are a courtesy, all information obtained should be verified by the policyholder.
If you need help filling out this form, please contact us at email@example.com or via phone at (510) 910-4449.