Insurance Verification Form

Insurance Verification Form

Please complete this form to verify insurance coverage for treatment at The Springboard Center.
Your Name

First NameLast Name
Patient Name

First NameLast Name
Your Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient’s Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Company
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holder Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Member ID#
Policy/Group#
Name of Employer (if insurance is through an employer)
Relationship to Patient
Insurance Company Provider Telephone #
Please enter a valid phone number.Format: (000) 000-0000.
Will the patient be utilizing FMLA leave while in treatment?
Should be Empty: