Insurance Verification Form
We will email you the results within 24 hours
Please fill out all applicable fields to verify your plan
You must be the patient. If under 18 years old, then you must be a parent, guardian or representative of the client.
PATIENT'S Name
*
First Name
Last Name
PATIENT'S Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
PATIENT EMAIL: (For minor's use Parent/Guardian's)
*
example@example.com
PARENT/GUARDIAN's full name REQUIRED if client is a minor
example@example.com
The Patient is the insurance SUBSCRIBER'S
*
Spouse
Child
Other
I'm the subscriber
Spouse/Child/Other: Please fill out the SUBSCRIBER'S information below:
SUBSCRIBER'S NAME
First Name
Last Name
SUBSCRIBER'S Date of Birth
-
Month
-
Day
Year
Date
"By signing below, I authorize Minds In Action Counseling and it's representatives to request and obtain my insurance benefits and coverage details on my behalf."
Front side-Upload Insurance Card
*
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Back side-Upload Insurance Card
*
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