Insurance Verification Request Form
If you receive this form, we are needing your most updated insurance information for our records. Please complete and submit back to us as soon as possible. Thank you.
Date
/
Month
/
Day
Year
Date
Client Name:
*
First Name
Last Name
Back
Next
PRIMARY INSURANCE
If you do not have insurance and are SELF PAY, please type "SELFPAY" below and type "0000" as member ID.
Primary Insurance Carrier Name
*
Please type the name of your insurance company
Member ID / Policy #
*
Please type your member ID as shown on your card.
Policy Holder's DOB:
-
Month
-
Day
Year
Please enter the DOB of the Policy Holder if it is someone other than the client.
FRONT of Primary Insurance:
Browse Files
Drag and drop files here
Choose a file
To help us verify your insurance faster, please upload the requested documents
Cancel
of
BACK of Primary Insurance:
Browse Files
Drag and drop files here
Choose a file
To help us verify your insurance faster, please upload the requested documents
Cancel
of
Back
Next
SECONDARY INSURANCE
Do you have a Secondary Insurance?
*
Yes
No
Secondary Insurance Carrier Name
*
Please type the name of your insurance company
Member ID / Policy #
*
Please type your member ID as shown on your card.
Policy Holder's DOB:
-
Month
-
Day
Year
Please enter the DOB of the Policy Holder if it is someone other than the client.
FRONT of Secondary Insurance:
Browse Files
Drag and drop files here
Choose a file
To help us verify your insurance faster, please upload the requested documents
Cancel
of
BACK of Secondary Insurance:
Browse Files
Drag and drop files here
Choose a file
To help us verify your insurance faster, please upload the requested documents
Cancel
of
Submit
Should be Empty: