EmailMeForm
Check Your Benefits
With this insurance information, we will be able to call your insurance company, find out what your benefits are (how many visits you are entitled to, what your co-pay may be, etc.) and other information we may need regarding your care.
Your Information
The information the insurance company will need from us to get the information we will need.
Your Name
*
First
Last
This field is for the patient who will be coming in.
Subscriber Name
*
First
Last
This field is for the person named on the insurance (may be the same person)
Email
We may contact you by e-mail and/or phone.
Phone
*
###
-
###
-
####
Alt. Phone
###
-
###
-
####
Birthdate of New Patient
*
MM
/
DD
/
YYYY
Preferred Method of Contact
Phone
E-mail
Alt. Phone
Try me at all of them
Insurance Company Information
Who and where we contact to get your benefits.
Do Not give your Social Security Number.
Insurance Company Name
*
Subscriber ID (Not Social Security Number)
*
Other Insurance ID Information (Not SS#)
Provider Information Line
*
###
-
###
-
####
Alternate Information Phone
###
-
###
-
####
Additional Information you would like to give us to help you, or that you think we may need. Giving any additional information you think we may need can speed up the process because if we need further info, we will have to contact you before we can give you accurate information.
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