Insurance Verification Form
We will email you the results within 24 hours
Please fill out all applicable fields to verify your plan
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
PATIENT EMAIL: (For minor's use Parent/Guardian's)
*
example@example.com
Phone Number
*
Please enter a valid phone number.
PARENT/GUARDIAN's full name
The Patient is the insurance SUBSCRIBER'S
*
Spouse
Child
Other
I'm the subscriber
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
*
Browse Files
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Choose a file
Cancel
of
Back side-Upload Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Continue
Continue
Phone number
*
First Name
Last Name
E-mail
*
for minors, add parent's email
Submit
Should be Empty: