Insurance Information
Please fill out this form as much as you can so we can give you the best estimate of what we will need to collect from you before your first appointment.
Email address *
Legal first name *
Your answer
Legal last name *
Your answer
Best phone number for you *
Your answer
What are you needing help with?
Your answer
How long have you been having trouble?
Your answer
Who referred you to COOR Wellness or how did you hear about us?
Insurance Company (& Plan if known)
Your answer
Date of birth *
MM
/
DD
/
YYYY
Alpha prefix (the letters before) + the ID number and your group number *
Your answer
Phone numbers on the back of the card *
Your answer
Plan ID
Your answer
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