Insurance Verification

Verify Your Insurane Online

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.

  • Max. file size: 50 MB.
  • 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.

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