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Insurance Verification

Point of Contact

Name of Person Completing Form

Email of Person Completing the Form

Phone # of Person Completing the Form

Client Information

Client's Legal Name (First and Last)

Client's Email (Required for ages 12+)

Client's Phone # (Required for ages 12+)

Client's Preferred Name

Client's Biological Sex

Client's Date of Birth

Street Address

City

Region/State/Province

Postal / Zip code

Insurance Information

Insured's/Payer's Name (First Name, Last Name)

Street Address

City

Region/State/Province

Postal / Zip code

Image of Insurance Card

Upload File

Upload supported file (Max 15MB)

Insurance Company's Name

Policy Number

Policy Group Number

If you are using EAP, please enter your EAP #

If you are using EAP, please enter the # of approved EAP Sessions and When EAP Sessions need to used by

Thank you! We will be in touch!

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