Insurance Verification

Please fill out the form below to verify your insurance coverage and we will contact you as soon as possible. All fields marked with an orange star are required.

We are in-network with most insurance companies.

Please call us to see if your HMO, PPO, or EPO insurance plan will cover your treatment. Or ask us about our affordable self-pay plans.

"*" indicates required fields

Patient Information

Hidden

Patient Full Name

Enter patient’s first & last name.

Patient Full Name*

Enter patient’s first & last name

Patient Date of Birth*

Enter patient’s date of birth (MM/DD/YYYY).

Patient Phone Number*

Enter patient’s phone number, including area code.

Patient Physical Address

Enter patient’s physical address (street, city, state, zip).

Patient Email Address

Enter patient’s email address.

Primary Policy Holder Information

Hidden

Policy Holder Full Name

Enter policy holder’s first & last name.

Policy Holder Full Name*

Enter policy holder’s first & last name

Policy Holder Date of Birth

Enter policy holder’s date of birth (MM/DD/YYYY).

Policy Holder Phone Number

Enter policy holder’s phone number, including area code.

Policy Holder Physical Address

Enter policy holder’s physical address (street, city, state, zip).

Policy Holder Email Address

Enter policy holder’s email address.

Insurance Information

Insurance Provider*

Enter insurance provider company name.

Insurance Provider Phone Number*

Enter insurance phone number, including area code.

Insurance Member Number*

Enter insurance member number (on insurance card).

Insurance Group Number*

Enter insurance group number (on insurance card).

Name

This field is for validation purposes and should be left unchanged.