Please fill out this form to verify insurance coverage
If you can only come in if your insurance will cover you, PLEASE note that below. Preauthorization and/or prescription may be required. All information is kept confidential and is ONLY used to verify coverage. We will NEVER share or sell ANY of your information, including email and phone.
Email Address: *
Your answer
Your Phone: *
Your answer
Name of patient (person seeking treatment): *
Your answer
Patient (person seeking treatment) date of birth: *
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Name of Insured - This may not be you, for example a parent or spouse may be the "insured:" *
Your answer
Insured's date of birth: *
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Your relationship to the insured: *
Required
Insurance company name: *
Your answer
Insurance company phone number(s) (Customer service and provider numbers if you have both:) *
Your answer
Insurance ID Number *For auto and workman's comp this will be a claim number, for health it will be a policy or customer ID number: *
Your answer
Claims mailing address: *
Your answer
General diagnosis, I'll get the exact codes later: (Headaches, low back pain, fibromyalgia, etc:) *
Your answer
Is there anything else you need to ask or tell us?For more detail, we can talk or email. amanda@countrymassage.net - 503-707-7400 *
Your answer
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