Check your Insurance – Cognitive Organics

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)

Your Name *

Name that the Insurance company has on record.

Gender *

Date of Birth *

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Clinician Information

State your appointment will happen in: *

Clinician you would like to see: *

Insurance Information

Insurance Name *

What is the name of your health insurance company?

Policy Number *

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 *

Primary Insurance Holder's Date of Birth

Relationship to Primary Insurance Holder *

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

Primary Insurance Holder's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Copy of the front of your insurance card

Click or drag a file to this area to upload.

Copy of the back of your insurance card

Click or drag a file to this area to upload.

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