Insurance Verification Inquiry Form – Netra Integrative Health Clinic

Insurance Verification Request Form

Please carefully read before requesting insurance verification.

All information submitted via the website is confidential.
Coverage varies from policy to policy; therefore, please complete the form below so that we may contact your insurance provider to obtain the details of your exact coverage.
Policies vary widely and it is important to fully understand the following when researching coverage:

Whether you are covered.
Whether your policy limits the number of visits per year.
Whether your policy limits the types of ailments it covers.
What your deductible is and whether it has been met.
What percentage of the cost your insurance company will cover.

READ CAREFULLY BEFORE SUBMITTING

Patient First Name

Patient Last Name

Policy Holder First Name

Policy Holder Last Name

PatientDOB

Patient Phone Number

Patient Email

Insurance Provider

Group Policy Number

Member ID Number

Insurance Company Telephone #

Reason for Visit

Questions