EmailMe Form - Insurance Verification Form

Name of Person Providing Insurance for Verification

First Last

Email

Phone

### - ### - ####

Insurance Carrier

800 Phone # for Behavior Health or Insurance Provider

### - ### - ####

Name of Primary on Insurance Policy

Name of Possible Client (if not primary)

Date of Birth

S ‌S ‌N

Insurance ID Number

Group #

Primary Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

If Plan Through Employer, Provide Name of Employer