Insurance Information

Please attach images of your insurance cards below. If you do not have insurance please check the box below stating that.

Patient First Name *

Last Name *

Phone *

Email *

Please select the option below that best respresents your situation. *

I have Group Health Insurance and will add my card information below.

I have Medicare and will add my information below.

I have a Medicare Advantage Plan and will add my information below.

I do not have insurance and will be paying out of pocket for my services.

Primary Insurance: Please attach a picture of the front and back of your primary insurance card below.

Front of Primary Insurance Card

Back of Primary Insurance Card

Secondary Insurance: If you have a secondary insurance, please attach a picture of that here

Secondary Insurance Front

Secondary Insurance Back

Please understand that if you have insurance but fail to submit it on this form, your first appointment will be treated as an out of pocket expense at our cash rates as we will not have time to verify insurance before your appointment. *

I understand

Signature *

Clear

By signing you are stating that everything listed above is true.