Medical Insurance Verification
Divine Beauty Bar will call you within 72 hours. This form is for all Durable Medical Equipment (Wigs, Mastectomy Items, Walkers, etc).
Patient Information
Name
*
First Name
Last Name
City, State and Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
N/A
Insurance Information
Primary Insurance Company
*
Policy Number/Member ID/Subscriber ID
*
Provider Insurance Phone Number (listed on the back of the insurance card)
*
Format: (000) 000-0000.
Subscriber's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
*
Group Number
*
Diagnosis (Alopecia, Type of Cancer, Lupus, etc?)
List any durable medical equipment needed (Mastectomy Bras, Breast Prosthetics, Lymphedema Compression Garments, Back Brace, Diabetic Shoes, Walkers, wheelchairs, cranial wig prosthesis,etc).
Consent to Release Information. Please list name of person you would like to Divine Beauty Bar to release information to regarding your insurance coverage (Stylist, Physician, Dermatologist, Oncologist, Facility Name, None, etc).
Submit
Should be Empty: