Tavia Health Appointment Request

Billing Information
Insurance provider*
Are you a BlueCard member?*
BlueCard members can see BlueCross BlueShield providers where they are living or traveling. Even if we are not in-network with your home BCBS plan, you can still use your insurance if your card has a suitcase icon (BlueCard).
If your card does not have a suitcase icon, your plan may not include BlueCard coverage.
We’ll review your benefits and confirm coverage and expected costs before any billable services.
Insurance category*
If Other, please specify your insurance category*
Thank you for reaching out! We are currently not in network with {insuranceProvider}.

At Tavia Health, we’re committed to making rehabilitation services more accessible to everyone. As we continue expanding our in-network insurance partnerships, we’re also exploring interest in self-pay (out-of-pocket) options.

If you'd be open to moving forward with a self-pay model for now, please let us know below.
Are you interested in a self-pay model?*

I'm interested in a self-pay modelI'm not interested in a self-pay modelI'm not sure
Even if you’re open to cash pay, please upload your insurance card so we can check your coverage if we become in-network and have a clinician available.
Please upload your insurance card so we can check your coverage once we’re in-network and can match you with a clinician.
Member ID*
The main ID number on your insurance card. We use this to check your coverage.
Group ID*
The group or employer number on your card (if you have one). Write N/A if it’s not listed.
Relationship to Subscriber*
Policyholder Gender*
Please select the option that matches how the policyholder is listed in the insurance company’s system. This is used to match the policyholder’s record and does not affect coverage or benefits.
Primary Insurance Holder First and Last Name*

First NameLast Name
Primary Insurance Holder Date of Birth*

MonthDayYear
Date
Picture of Front of Insurance Card*

Cancelof
Picture of Back of Insurance Card*

Cancelof
Do you have a secondary insurance policy?*

YesNo
Secondary Insurance
Secondary insurance provider*
Are you a BlueCard member?*
BlueCard members can see BlueCross BlueShield providers where they are living or traveling. Even if we are not in-network with your home BCBS plan, you can still use your insurance if your card has a suitcase icon (BlueCard).
If your card does not have a suitcase icon, your plan may not include BlueCard coverage.
We’ll review your benefits and confirm coverage and expected costs before any billable services.
Insurance category*
Member ID*
The main ID number on your insurance card. We use this to check your coverage.
Group ID*
The group or employer number on your card (if you have one). Write N/A if it’s not listed.
Relationship to Subscriber*
Policyholder Gender*
Please select the option that matches how the policyholder is listed in the insurance company’s system. This is used to match the policyholder’s record and does not affect coverage or benefits.
Primary Insurance Holder First and Last Name*

First NameLast Name
Primary Insurance Holder Date of Birth*

MonthDayYear
Date
Picture of Front of Insurance Card*

Cancelof
Picture of Back of Insurance Card*

Cancelof

Referral
Do you have a referral?*

YesNo
Please upload PDF of referral*

Cancelof
Please note: Your insurance plan may require a physician referral as a condition for coverage. Please ensure any required referral is obtained prior to your appointment. Tavia Health will provide you with further instructions as applicable.
Acknowledgements
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Tavia Health Appointment Request

Parent / Caregiver Details

Patient Information

Billing Information

Secondary Insurance

Referral

Acknowledgements