Web Insurance Payer Form

Insurance Payer / Reimbursement Form

In-Network Coverage: Aetna, Cigna, Empire Plan, NYSHIP, United Health Care
Please fill out our quick Insurance Payer / Reimbursement Form.

Once complete, you will be redirected to submit a CC authorization for your copay, choose your Dietitian Nutritionist, and Schedule your First Appointment if you have not already.

Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Carrier*
Insurance Subscriber Number*

Identification & Insurance Verification
Front of Insurance Card*
Back of Insurance Card*
Drivers License*

Once Your Insurance Is Submitted, Well-Choices Will Contact You With Exact Costs of Copay / Coinsurance and Coverage Prior to Your First Appointment.

Please allow 24hrs for Eligibility of Benefits Verification
Should be Empty: