Let's Verify Your Insurance

Full Legal Name *

Phone *

Email *

Date Of Birth *

Your Insurance Carrier? *

What Is Your Member ID Number? *

What Is Your Group ID Number? *

Are you the primary policy holder? *

Yes

No

Do you have a secondary insurance plan? (Even if massage isn't a covered benefit) *

Yes

No

If YES to the previous question. Enter the secondary policy holders information below:

Full Name
Date Of Birth
Member ID
Relationship To The Subscriber

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Are you a staff member filling out this form for a patient?

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