Telehealth Insurance Eligibility Verification

Telehealth Insurance Eligibility Verification

Complete this form to verify your insurance eligibility for telehealth services with WTS Medical Staffing.
Patient Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance Information
Insurance Payer*
Member ID*
Group Number*
Plan Type*
Upload Front of Insurance Card*

Cancelof
Upload Back of Insurance Card*

Cancelof
Referring Provider*
Reason for Telehealth Visit*
Should be Empty: