New Client Insurance Verification

Please fill out this form with your insurance information so that we can verify your insurance coverage prior to your appointment.

Verification of your insurance coverage is required before your appointment. If your insurance benefits have not been verified prior to your appointment you will need to pay the time-of-service rate ($70/hr).

After you have submitted this form, we will contact you with your coverage information within 1-4 business days.

Email address *
Name *
Email *
Who is your insurance carrier? *
Phone number *
What is your Insurance Member ID #? *
Are You the Primary Insured? *
What is your date of birth? *
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