Check Your Insurance Benefits

CLIENT'S INFORMATION (Individual Receiving Services)

Name: *

Date Of Birth (mm/dd/yyyy): *

Gender *
---MaleFemale

Street Address: *

City: *

State:*
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Zip: *

Phone Number (xxx-xxx-xxxx): *

Email Address: *

Diagnosis (if applicable):

INSURED INFORMATION (Parent, Guardian, Responsible Party)

Insurance Company: *

Identification Number: *

Group / Plan Number: *

Employer:

Insured's Name: *

Date Of Birth (mm/dd/yyyy): *

Gender *
---MaleFemale

Email Address:

Please upload a copy of the front and back of your insurance identification card: *