Insurance Verification Form

Insurance Verification

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

Well-Choices will contact your insurance provider to confirm your benefit eligibility.

Once confirmed, Well-Choices will email and SMS your coverage options, and send you a link to schedule your first appointment.

If you already know nutrition counseling is included in your insurance plan, you can bypass the confirmation and schedule your first appointment after completing this form.

Identification & Insurance Verification
Front of Insurance Card*
Back of Insurance Card*
Do you have a secondary insurance?

YesNo
Front of Insurance Card*
Back of Insurance Card*
Drivers License*
Well-Choices has permission to send my benefit verification results to me via email and sms, as well as information about nutrition and dietitian options.*

I, agree
Should be Empty:

Insurance Verification