Verify Insurance Benefits

First Name

Last Name

Date of Birth

Phone Number

Email Address

Insurance Information

Insurance Provider

Member ID

Group Number

Policy Number

Relationship to Policyholder

Policyholder / Subscriber Name

Policyholder / Subscriber Date of Birth

Insurance Customer Service Phone

Insurance Card — Front

Choose a file or drag & drop hereMax size: 10MB (.jpg,.jpeg,.png,.pdf)

Upload a clear image or PDF of the front of your insurance card.

Insurance Card — Back

Choose a file or drag & drop hereMax size: 10MB (.jpg,.jpeg,.png,.pdf)

Upload a clear image or PDF of the back of your insurance card.

Identification & Documents

Photo Identification

Choose a file or drag & drop hereMax size: 10MB (.jpg,.jpeg,.png,.pdf)

Upload a clear copy of a valid government-issued photo ID.

Additional Documents

Choose a file or drag & drop hereMax size: 10MB (.jpg,.jpeg,.png,.pdf,.doc,.docx)

Upload any additional documents requested by our office.

Intake Information

Reason for Seeking Care

Current Medications

I understand that I may be asked to complete additional intake and consent forms before receiving services.

I authorize the practice to verify my insurance eligibility and benefits using the information I have provided.

I understand that insurance verification does not guarantee coverage, authorization, payment, or that all services will be covered by my insurance plan.

I confirm that the information and documents I have provided are accurate and complete to the best of my knowledge.

Electronic Signature

Draw signature above

By signing, I confirm that I have reviewed and agree to the statements above.

Verify Insurance Benefits

Insurance Information

Identification & Documents

Intake Information

Quick Links

Contact Info

Quick Links

Contact Info