Insurance Verification

Tricare-Specific Insurance Information
- Your Driver's License or Photo ID
- A Device with a Touchscreen and a Working Camera
- Your Insurance Card (if you are using insurance)
If you get started and find that you will need to complete the form later, click "save" at the bottom, and you will be asked to enter your email. You'll be sent a link to complete it later.

Before you get started, you will need:
Name

First NameLast Name
Date of Birth

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you requesting sessions be phone or video for telehealth
Insurance Card Front (If you would like to use your benefits)
Insurance Card Back
Are you the primary policyholder or are you a dependent (usually spouse or child)?
Policyholder Name

First NameLast Name
Policyholder Date of Birth

MonthDayYear
Date
Policyholder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policyholder Phone Number

Area CodePhone Number
Your Relationship to Policyholder

Tricare-Specific Insurance Information