Insurance Verification Form

Please take a moment to complete the form below, and a member of our team will reach out to you as soon as possible. We appreciate your time and look forward to assisting you. Thank you!

Patient Name

First Name

Last Name

Point of Contact (if not the patient listed above, who should we reach out to?)

First Name

Last Name

Patient Date of Birth:

MM

DD

YYYY

Phone

(###)

###

####

Email

Primary Insured Name

First Name

Last Name

Primary Insured Date of Birth

MM

DD

YYYY

Primary Insured Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company Name

First Name

Last Name

Insurance ID #

Insurance Group #

Will the patient be getting FMLA Leave while in Treatment?

FMLA refers to the Family and Medical Leave Act, which is a federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year with no threat of job loss. FMLA also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working.

Insurance Verification Form

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