Tavia Health Appointment Request

Billing Information
Insurance provider
Insurance provider
Insurance category
If Other, please specify your insurance category
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.
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?
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?
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?
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
Should be Empty:

Tavia Health Appointment Request

Parent / Caregiver Details

Patient Information

Billing Information

Secondary Insurance

Referral

Acknowledgements