Insurance Verification |

Insurance Verification Form

Please note: You are responsible to know and verify your benefits prior to any services. It is also your responsibility to notify the office of all changes in your insurance. Please have your insurance card available at your appointment as we will need a copy.

Complete the below insurance Information

First Name

Last Name

Date of Birth

Address

City

State/Province

Zip/Postal

Phone

Are you the primary on the insurance?

yes

First name of Primary

Last name

Date of birth of primary

Insurance information

Insurance company name

Insurance Policy or ID number

Insurance group number

Insurance phone number

Benefit Information

Number of approved visits

Do you have a deductible?

yes

Amount of deductable

How much of deductable has been met?

Do you have a co-pay?

yes

how much is it?

Do you need a referral for counseling?

yes

If yes, you are responsible for obtaining that.

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Download a blank PDF form for your records