Insurance Intake Insurance Intake By clicking on "Submit" at the bottom of the page, you attest that you are the patient (or legal guardian) & that you consent to us verifying your insurance benefits & contacting you with the information. Note: An *asterisk* indicates a required field. Patient Name (full legal name)*Address*Phone number*Patient Birthdate*Reason for TreatmentHow did you hear about us?Primary Insurance*Policy Number*Group ID*Insurance phone number (typically listed on the back of your card)*Policy holder's name (if different than patient)Policy holder's birthdate (if different than patient)Do you have a secondary insurance? If so, please list here. Otherwise, enter "No."*Policy Number (secondary insurance)Group ID (secondary insurance)Insurance phone number (secondary insurance)Policy holder's name (if different than patient)Policy holder birthdate (if different than patient)Your doctor's name*Your doctor's phone number*Have you contacted your doctor to request a referral?* Yes Is anyone coming to your home to check blood pressure, provide nursing or therapy service?* Yes No NameThis field is for validation purposes and should be left unchanged.
