Verify Insurance Benefits
Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
Date of birth
*
-
Month
-
Day
Year
Date
Phone number
*
Please enter a valid phone number.
Email
*
example@example.com
State
*
Please Select
CALIFORNIA
FLORIDA
GEORGIA
ILLINOIS
INDIANA
OREGON
PENNSYLVANIA
Member ID
*
Insurance company
Please Select
Self pay
Aetna
Anthem
Blue California
Cigna
Health Net
Health Smart
Humana
Medicare
Tricare
United Healthcare
Group ID (optional)
Upload insurance card (Front and back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: