Free Insurance Verification Website Form
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 *
Legal last name *
Best phone number for you *
What are you needing help with?
How long have you been having trouble?
Who referred you to COOR Wellness or how did you hear about us?
Clear selection
Are you looking for In Office Care, Telemedicine or Both?
Clear selection
Insurance Company (& Plan if known)
Date of birth *
MM
/
DD
/
YYYY
Alpha prefix (the letters before) + the ID number and your group number *
Phone numbers on the back of the card *
Plan ID
Submit
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