Tavia Health Appointment Request

Billing Information
Insurance provider*
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*
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*
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*
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