PLEASE COMPLETE BOTH PART 1 & PART 2

Part 1: Insurance Form

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First Name: *

Last Name: *

Date of Birth: *

E-mail address: *

Your Cell Phone Number *

Health Plan Name (i.e., United Healthcare, Blue Cross) *

Insurance ID# *

Tel # on back of Insurance Card for Providers or Eligibility *

SECONDARY Insurance Company

SECONDARY Insurance ID#

Your Mailing Address (Cannot process without all these details: Street, City, State, Zip) *

If you've been given an Auth, add the long Authorization #

If you've been given an Auth, add the 5-digit CPT Code (i.e. 90791 or 90792)

Medical Group (i.e. PIH Health/Applecare MG) *

YES/NO: I know that I must also fill the other form below called "Part 2 - Online Intake" in order for my application to be complete. *

Captcha (spam protection code) *

Note: Fields marked with * are required

Once you submit both forms, the biller will IMMEDIATELY start working on verifying your insurance, please give your insurance up to 2 weeks to let us know if you are approved. We will text your cell at that point.

You can also text our main office number to let us know that all is submitted or if any questions:

Text (not call or voicemail) to 562-947-8832 for quickest response

Part 2: Online Intake (Click the BUTTON below)

Part 2: Online Intake - CLICK HERE (takes you to another website)

TIPS:

- This opens a new webpage, so please complete Part 1 (Insurance) first

- Complete Part 2 (Intake) on a computer (not phone) for best results

- Before you click on Part 2 (Intake)... make sure you have photos of your ID and Insurance (Front/Back) already sitting on your computer desktop so that you can upload them into the form

***PLEASE COMPLETE BOTH PART 1 & PART 2***