Let's Check if You're Covered
Answer a few quick questions and we'll confirm your coverage (or your cash-pay rate) within 24 hours. Your assigned Registered Dietitian will send you an email with this information.
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
State You Live In
*
Sex Assigned at Birth
*
Male
Female
Intersex
Prefer not to say
Height (Feet)
*
Height (Inches)
*
Weight (pounds)
*
Have you ever been told that you have diabetes or prediabetes?
*
Diabetes
Prediabetes
No
Have you unintentionally lost more than about 10 pounds in the last 6 months?
*
No
Yes
Unsure
Have you been eating less than usual because of poor appetite?
*
No
Yes
Insurance Information
Name of Policy Holder
*
First Name
Last Name
Insurance Company/Payer Name
*
Please Select
Aetna
Anthem
Blue Cross Blue Shield
UHC
Cigna
Medicare
Select Health
Other
Which state is your plan based in?
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Member ID Number
*
Group Number
Consent & Acknowledgements (all must be accepted)
*
I authorize SurgicalRx to verify my insurance benefits
Submit
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