GHR Verification of Benefits

Verification of Benefits

Radically Person-Centered Care
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Insurance Holder Information

Only fill out information for the primary insurance account holder information below
Primary Account Holder Name*

First NameLast Name
Primary Account Holder Date of Birth*

MonthDayYear
Primary Account Holder Email*
example@example.com
Primary Account Holder Phone Number*
Please enter a valid phone number.
Primary Account Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How are you entering insurance information?*

Manually enter informationFile upload
File Upload

Cancelof
Primary Insurance Company
Insurance Group Number
Insurance ID Number
Authorization to Leave Messages, Receive Emails, and Receive Text Messages

I hereby authorize that phone messages, emails, and/or text messages are allowed to be left at the above email address / phone number(s) regarding my prescriptions, appointments, and care from the Advaita Health Ventures, LLC, DBA the Advaita Collective, and its affiliated companies, Advaita Integrated Medicine, PLLC and Green Hill Recovery, LLC. I understand that my electronic signature is the legal equivalent of my manual/handwritten signature on this document.
Signature

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Verification of Benefits