Check your Insurance

Want to know if we are In-Network before scheduling an appointment?

Fill out this form and we will get back with you within 3 business days.

(Please only fill out this form if you have not already scheduled an appointment. If you have scheduled an appointment we will already check your insurance before your first appointment)

Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

Email(Required)

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Appointment information

State your appointment will happen in:(Required)

Clinician you would like to see

Insurance Information

Insurance Name(Required)

What is the name of your health insurance company?

Policy Number(Required)

What is the policy number of your insurance?

Group Number

What is the group number of your insurance, if applicable?

Primary Insurance Holder's Name(Required)

First Last

Primary Insurance Holder's Date of Birth(Required)

Relationship to Primary Insurance Holder(Required)

What is your relationship to the Primary Insurance Holder? (i.e. self, spouse, child etc)

Primary Insurance Holder's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Copy of the front of your insurance card

Max. file size: 1 GB.

Copy of the back of your insurance card

Max. file size: 1 GB.