***Part 1: Insurance Form***

Your form message has been successfully sent.
You have entered the following data:

Please correct your input in the following fields:
Error while sending the form. Please try again later.

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)


- 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

Print | Sitemap
© Healthy Brain Center 2024