RELAX SPA
Please allow us from two to three days to verify your insurance coverage. Thanks
Insurance Verification
First Name
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Last Name
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Address
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City, State & ZIP
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Phone
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Email
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Date of Birth
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Sex
Patient, Subscriber # / ID #
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Group #
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Insured Name & ID # (If Different from patient)
Your answer
Relationship to Insured
Insurance Co Name
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Ins. Co Phone #
Your answer
Chief Complaint of Primary Diagnosis
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Comments
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