Free Chiropractic Clinic Insurance Verification Form

Kindly fill out this form to help us verify your insurance coverage and benefits.
Name
Date of Birth
Email Address
Phone Number
Address
Insurance Information
Insurance Provider
Policy Number
Group Number
Insurance Provider Phone Number
Authorization to Verify Benefits
I authorize the clinic to contact my insurance provider to verify benefits and coverage on my behalf. I understand that verification of benefits is not a guarantee of payment, and I am responsible for any fees not covered by my insurance plan.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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