First Name

Last Name

Email Address

Phone

Subject

Are you using health insurance? (Benefit checks are done as a courtesy. It is not a guarantee of payment or approval of medical necessity.) Are you using health insurance? (Benefit checks are done as a courtesy. It is not a guarantee of payment or approval of medical necessity.) Yes No

Name on Insurance Card

Insurance Company

Subscriber ID #

Date of Birth

Company Employed by (Group Insurance plans only)

Message

How did you find us? How did you find us? Google Yelp Referral Other

Other