Insurance Coverage Verification Request

Date of Birth

MonthDayYear
Date
Insurance Coverage Verification Request

Securely transmit your insurance information. Encrypted and HIPAA complaint for the protection of your privacy.
Name

First NameLast Name
Social Security Number (for insurance verification and billing purposes)
Gender at birth
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason(s) For Being Seen
(Chronic low back pain, neck pain, left shoulder pain, etc.)
Employer (if your insurance is through your job or your spouse's job)
Is your injury or illness due to any of the following:

Service (military) connected injury (VA referral required)Auto AccidentWork AccidentSlip & Fall or Personal InjuryNone of the above
If yes to the above, what is the estimated date the injury occurred?
Upload a photo of the FRONT of your insurance card
Upload photo of the BACK of your insurance card
Cant upload a photo? You may upload a copy of your Insurance card here:

Cancelof
Can't upload your insurance card? No worries. Simply enter the information below and we'll make a copy when you arrive. Please be sure to double check the information.
Name of Insurance Company
Member ID Number
Group Number (not Group Rx) *Not all insurance cards will have a Group Number
Insurance phone number off the back of the card (Provider/Member/Customer Service number)
Clear
Date

MonthDayYear
Date
Should be Empty: