Insurance coverage verification
Please note, just because we (Body Balance Rolfing and Massage) are checking to verify coverage there is no guarantee that you have coverage for our services, and deductible and copayments will apply. If you can only come in if your insurance will cover you, PLEASE note that below. Additionally, it can take about a week (sometimes) to get the information, so please don't expect immediate answers. Preauthorization or preapproval may be required. Some insurance companies require a prescription. Thank you.

All information is kept confidential and is ONLY used to verify coverage. We will NEVER share or sell ANY of your information, including email and phone.
Email address *
Insurance company name *
Insurance ID Number *
For AUTO and WORKMAN'S COMPENSATION this will be a claim number, for HEALTH it will be a policy or customer ID number.
Name of patient (person seeking treatment): *
Name on record with insurance company, not a nickname.
Birthdate of patient (person seeking treatment) *
MM
/
DD
/
YYYY
Your phone (even if you're not seeking care) *
Name of Insured - This may not be you, for example a parent or spouse may be the "insured." *
Name on record with insurance company, not a nickname.
Insured's date of birth *
MM
/
DD
/
YYYY
Your relationship to the insured: *
Required
Insurance company phone number(s) (Customer service and provider numbers if you have both.) *
General diagnosis, I'll get the exact codes later: *
(Headaches, low back pain, scoliosis, etc.)
Type of Insurance *
Is there anything else you need to ask or tell us?
For more detail, we can talk or email. jenny@BodyBalancePortland.com - 503-345-7660
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy