Insurance Benefit Check Form
At Portland Healing Space, we accept most major health insurance plans as well as auto accident and workers’ compensation claims. Please complete and send this form to receive your complimentary insurance benefits check.
First Name *
Your answer
Last Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Email Address *
Your answer
Phone Number *
Your answer
Insurance Company *
NOTICE: We are in-network with most but not all of these companies
If other, please specify
Your answer
Member ID # *
Your answer
Group ID # *
Your answer
Provider Line Phone Number
Usually on the back of your insurance card
Your answer
Questions? Call us!
503-894-9437
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