Insurance Verification Request
Please complete the information below to allow verification of your insurance benefits prior to scheduling. Submission does not guarantee coverage or payment.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Insurance Information
Insurance Company Name
*
Please Select
Blue Cross Blue Shield
WellSense
Cigna
Harvard Pilgrim
Tufts Health Plan (Point32Health)
*This practice is currently credentialed with the insured companies listed
Primary Insurance Company name
*
Insurance Plan Name (if known)
Member ID #
*
Group #
Are you the Primary Policy holder?
*
Please Select
YES
NO
Enter the Full Name of the Primary Policy Holder
*
First Name
Last Name
Enter the Date of Birth of the primary policy holder
*
-
Month
-
Day
Year
Date
Subscriber's Relationship to the Primary Policy Holder?
*
Spouse
Child
Other
Upload Front of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Back of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Acknowledgment of Insurance Verification Process: I understand that insurance benefits are not guaranteed and that final eligibility is determined by my insurance carrier at the time of service. I acknowledge I am responsible for any services not covered by my plan.
*
Submit
Should be Empty: