PLEASE COMPLETE BOTH PART 1 & PART 2 BELOW

Part 1: Online Intake - CLICK HERE (Easiest on a computer)

Part 2: Insurance Info

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First Name: *

Last Name: *

Date of Birth: *

Your 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 (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) *

Note: Fields marked with * are required

Once you submit both forms, the biller will IMMEDIATELY start working on verifying your insurance, please give us a few days to call you back to schedule your appointment once you are approved.

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

Part 2: Insurance Info

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PLEASE COMPLETE BOTH PART 1 & PART 2 BELOW