Insurance Verification Form
1. Please enter your information
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Date of Birth:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Insured Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please indicate how you want to give us your insurance information. Do you want to:
Write your insurance information
Upload pictures of the front and back of your insurance card
Provide both
3. Insurance Company
Insurance Group Number
Member ID / Policy # (please include no space or dash)
Primary Insured Date of Birth
Insured Date of Birth
10. Front of Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
11. Back of Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
12. Please upload a picture of your photo ID such as a driver's license
Browse Files
Drag and drop files here
Choose a file
Cancel
of
By typing your name in the box below, you agree to receive communication from Rivia Mind.
Name
Date
-
Month
-
Day
Year
Date
Submit
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