Client Intake Form

Client Intake Form

Thank you for your interest in working with Suade Health. Please complete this form so our team can review your information, and we’ll be in touch with next steps once your case has been evaluated.
Name*

First NameLast Name
Middle Name - If not applicable, leave blank
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMalePrefer not to say
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Who referred you to us?*
If Other, who?*
Surgery of interest*
Surgery Status*

Scheduled or deposit paidAlready completedNeither
Expected surgery date*

MonthDayYear
Date - If not scheduled, select best estimate
Completed surgery date*

MonthDayYear
Date
Estimated surgery cost*
Enter dollar amount
Chosen surgeon name*
Have you taken any insurance steps?*

YesNo
Insurance steps taken (select all that apply)

Prior authorizationGap exceptionClaim appealOther
Prior Authorization Status*

DeniedApprovedPending
Gap Exception Status*

DeniedApprovedPending
Claim Appeal Status*

DeniedApprovedPending
Reimbursed amount thus far*
Enter dollar amount
What other insurance step have you taken?*
Primary Insurance Provider*
Member ID
Group Number
Insurance Card (Front)
Insurance Card (Back)
Anything else you want to share?

0/50
Suade Health helps patients secure insurance approval and maximize reimbursement for life-changing procedures. We manage every step—from prior authorization and gap exceptions to overturning denials and maximizing reimbursement—handling all insurer communication, deadlines, and documentation so nothing falls through the cracks and patients can focus on their recovery.

Suades service fee is 25% of savings provided, with an upfront non-refundable $1000 deposit that is applied to the final success fee.

I acknowledge that I have read and agree to the above and understand Suade Health’s service structure and fees.
Signature*

Clear
Date*

MonthDayYear
Date
Qualification Status
Claim Delta
Should be Empty: