Insurance Verification

Full Name *

Date of birth *

Phone *

Email *

Preferred Appointment Date *

Message *

Preferred Location *

Upload front side of insurance card *

Upload back side of insurance card *

I acknowledge and agree that the information I am submitting, including my insurance details and any uploaded identification documents, may contain Protected Health Information (PHI). I authorize Advanced Neurosurgery Associates to collect, use, and disclose this information solely for the purpose of verifying my insurance eligibility, benefits, and coverage related to medical care and treatment.

I understand that this information will be transmitted and stored through a secure, HIPAA-compliant system, and will not be shared with any third parties except as required for insurance verification or as permitted by law. I also consent to be contacted by the office regarding my insurance verification and appointment scheduling.

By checking this box, I confirm that I have read, agree to our privacy policy and understood this authorization and consent to the use of my information as described above.