Verification of Benefits

Patient Name *

Patient Date of Birth *

Policy Holder Name *

Policy Holders Zip Code *

Policy Holder Date of Birth *

Insurance Provider *

United Healthcare requires that the patient/policy holder to call in and give permission for Forte Strong to obtain the out of network benefits for behavioral health services. In order to process this VOB request you will need to call in and give this permission for Forte Strong to verify your benefits.

Insurance Policy # *

Insurance Phone Number *

Have you called United Healthcare for VOB permission? *

YES

Who Should Get The Results *

Email *

Phone *

FRONT of Insurance Card *

Please upload an image of the FRONT of your Insurance Card

BACK of Insurance Card *

Please upload an image of the FRONT of your Insurance Card

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