Insurance Benefits Check
This is an insurance benefits check form for Lockport Wellness. If you would like us to see if you have insurance coverage, please complete this form. We will contact you via email within one week to notify you of your coverage.

If you would prefer to call or fax us your information instead, you may do so by calling 716-727-0616, or fax it to 716-727-0616. (Our fax and phone number are the same number).

Patient Information
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
E-mail Address *
Your answer
Phone Number *
Your answer
Address *
Your answer
Insurance Company Information
Policy Number *
Your answer
Insurance Company Name *
Your answer
Insurance Company Provider's Phone Number *
Please look on back of card for 'Provider's Phone Number'. If there isn't one, please list the general customer service number listed on the back of your card.
Your answer
Policy Holder Information (if different than the patient)
Policy Holder Name
Your answer
Policy Holder Date of Birth
MM
/
DD
/
YYYY
Policy Holder Gender
Policy Holder's Relationship to Patient
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.