Name *

First

Last

of Person Providing Insurance for Verification

Email *

Your Phone Number *

Insurance Provider Information

This 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 Carrier

800 Phone Number

for Behavior Health or Insurance Provider

Insurance ID Number

Group Number

Name of Primary on Insurance Policy

First

Last

Name of Possible Client (if not primary)

First

Last

Date of Birth

Primary Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance coverage

Insurance Provider Information