Insurance Verification Form

Insurance Verification Form
Thank you for considering Nepenthe Wellness Center for your well-being. We understand that navigating insurance can be a crucial step in your healthcare journey. Please take a moment to fill out the form below with your insurance details. Our dedicated team will promptly review your information and work diligently to check your insurance benefits.

Once we have completed the verification process, we will reach out to you to discuss the details of your coverage and provide you with a clear understanding of any potential out-of-pocket expenses associated with our ketamine treatment services. Our commitment is to ensure transparency and support you in making informed decisions about your healthcare.
Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*
Insurance Information
Primary Insurance Co.*
Member ID*
Primary Insurance Co
Group No*
Primary Insurance Phone No*
Subscriber's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Subscriber's Relationship to Patient*
Should be Empty:

Patient Information