Insurance Verification Form

Company

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

We strive to ensure you have the most accurate information regarding your insurance benefits for therapy. Please take 5 minutes to fill out this form. We will do a benefit check on your insurance with the information provided and inform you of the expected cost of therapy for your child. You are encouraged to also contact your insurance company personally and request benefit information:

Patient Date of Birth

Primary Insurance

Is the insurance state: Medicaid / Medicare / Apple Health / Molina / UHC / Coord Care:

Primary Insurance

Relationship

Date of Birth

Phone

Employer

(if applicable)

Name of Insurance

(be as specific as possible)

Member ID

(include letters if present)

Group ID

(include letters if present)

Insurance Phone Number

(Customer service if present)

Secondary Insurance

Is the insurance state: Medicaid / Medicare / Apple Health / Molina / UHC / Coord Care:

Secondary Insurance (if applicable)

Relationship

Date of Birth

Phone

Employer

(if applicable)

Name of Insurance

(be as specific as possible)

Member ID

(include letters if present)

Group ID

(include letters if present)

Insurance Phone Number

(Customer service if present)