First Name

Last Name

Email *

Phone *

Name of Primary Insurance Holder as written on the card

Home Address Associated With Insurance Card

DOB of Primary Card Holder

Name of Insurance Company

Insurance Company Address

Benefits/Eligibility/Provider phone number

Member Number

Picture of Insurance Card Back and Front *

Picture of Insurance Card Back and Front

Notes/Instrucitons/Requests

Notes/Instructions/Requests

Captcha

I consent to receive non-marketing text messages from Hearing Benefit Services regarding my insurance verification request, appointment reminders, and account-related updates. Message frequency varies. Message & data rates may apply. Text HELP for help or STOP to opt out.

I consent to receive marketing and promotional text messages from Hearing Benefit Services including special offers, hearing health tips, product updates, and service announcements, at the phone number provided. Message frequency varies. Message & data rates may apply. Text HELP for help or STOP to opt out.