Verify Insurance

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Steps to Insurance Verification

Fill out the form below, or call us for a free verification of benefits
Complete a clinical screening while our team calls your insurance
Review insurance benefits and financial obligations (if they apply)

Verify Insurance Form

Fill out the form below to verify your insurance benefits and we’ll get back to you as soon as possible. Please note that all fields are required.

Name *

First

Last

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Email *

Phone *

Client Information

Client Name *

First

Last

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Client Date of Birth *

Client Email *

Client Phone *

Client Insurance Member ID *

Client Insurance Group ID (copy) *

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Information

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Provider Name *

Provider Phone *

Provider Name *

First

Last

Layout (copy) (copy)

Provider Date of Birth *

Primary Subscriber Drivers License / ID Number *

Primary Subscriber SSN Number *

Primary Subscriber Insurance Member ID *

Primary Subscriber Insurance Group ID *

Provider Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please upload a photo of the front and back of your current insurance card

Click or drag files to this area to upload. You can upload up to 2 files.

Accepted file types: jpg, png, pdf, Max. file size: 10 MB, Max. files: 2.

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