Verify My Benefits Name(Required) First Last Phone(Required)Email(Required) Questions or RequestsIf you would like us to verify your insurance benefits and provide more details about your coverage before scheduling, please also complete the information below. This form is submitted through a secure format and follows HIPAA guidelines to ensure your personal information remains private and protected.Date of Birth MM slash DD slash YYYY Type of InsuranceMember ID NumberGroup Number (if applicable)Are you the primary policy holder? Yes No If no - Primary policy holder's name and date of birthMember's Services/Customer Service phone number on the back of the cardIf you have secondary insurance, please provide the same information in this box
