Insurance coverage Verification Form Please enable JavaScript in your browser to complete this form.Name *FirstLastof Person Providing Insurance for VerificationEmail *Your Phone Number *Insurance Provider InformationThis part of the form is optional, it saves us both time, but you can just fill out your name, email, and phone number fields and we will call you to discuss your insurance coverage options. Upload Insurance Card Click or drag files to this area to upload. You can upload up to 2 files. If your upload a photo or scan of your medical insurance card, you can skip filling out the rest of this form. Insurance Carrier800 Phone Number for Behavior Health or Insurance ProviderInsurance ID NumberGroup NumberName of Primary on Insurance PolicyFirstLastName of Possible Client (if not primary)FirstLastDate of BirthPrimary AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSubmit