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 contact you at this number to go over your coverage.
Date of Birth*

MonthDayYear
Insurance Carrier Name*
i.e. Health Partners, Medica, United Healthcare
Member ID Number*
Group Number (optional)
Please verify that you are human*
Your information is 100% secure and protected under HIPAA guidelines. Coverage details provided are based on information from your insurance company and do not guarantee payment or approval for services.
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Want to Know Your Coverage Before You Start?