Health Insurance Benefits Request Form

Want to Know Your Coverage Before You Start?

Simply share your insurance information below, and within one business day, we’ll call you with a complete breakdown of your coverage and out-of-pocket costs.

What we’ll verify for you:
- Physical therapy benefits and visit limits
- Nurse practitioner evaluations and medical care
- Diagnostic testing coverage (including X-rays)
- Deductible and copay amounts
- Pre-authorization requirements, if any
Your Name*

First NameLast Name
Email*
example@example.com
Phone Number*
We will use this number to contact you within 1 business day.
Date of Birth*

MonthDayYear
Used only to check insurance benefits.
Insurance Carrier Name*
i.e. Health Partners, Medica, United Healthcare
Zip Code*
Member ID Number*
Group Number (optional)
Please verify that you are human*
Your information is secure and protected under HIPAA guidelines.
Insurance details are reviewed based on plan information provided and will be discussed during your follow-up conversation.
Should be Empty:

Want to Know Your Coverage Before You Start?