Insurance Verification Form – Love Counseling Center
Please provide your insurance details to verify your coverage for counseling services.
Client Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
State
*
Insurance Provider
*
Please Select
Aetna
Cigna
UHC
Oscar
Blue Cross Blue Shield of Massachusetts
Oxford
Other
Group Number (if applicable)
Insurance Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please Upload Your Insurance
Upload Insurance Card (Front)
*
Upload a File
Drag and drop files here
Choose a file
Front side of your insurance card
Cancel
of
Upload Insurance Card (Back)
*
Upload a File
Drag and drop files here
Choose a file
Back side of your insurance card
Cancel
of
Policy Holder's Name (if different from client)
First Name
Last Name
Driver's License
*
Upload a File
Drag and drop files here
Choose a file
Front side of your driver's license
Cancel
of
Additional Information or Notes
Terms & Conditions
*
I understand that insurance verification is not a guarantee of payment, and I am responsible for any unpaid balance.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Verification
Should be Empty: