Insurance Verification

We understand you are financially responsible for the medical services rendered. You may pay in full, or we will file a claim on your behalf if you complete the authorization and insurance form below (if you have secondary coverage, please attach it also). If you have no insurance coverage, cannot pay in full, or are not the financially responsible party, please contact us.

Insurance Card Photo Upload
Max. file size: 50 MB.
Insurance Company Name*
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Subscriber's Full Name*
First Last
Subscriber's Phone Number*
Patient's Full Name (if different than Subscriber)
First Last
Relationship to Subscriber
Account Number
Group Number*
SSN: (optional)
Policy/Identification No:*
LIFETIME SIGNATURE AUTHORIZATION*
I request that payment of insurance benefits be made on my behalf for services furnished to me. I authorize any holder of hospital or medical information about me to release to the above-named insurance carrier, or any insurance carrier that I provide, and its agents and carriers, as well as any information or documentation needed to determine these benefits or benefits payable for related services. I understand that this authorization may be used by the supplier for all services now and in the future until such time that I revoke this authorization in writing.
- I agree
Signature (Print Full Name)*
Your Email*
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