Please supply the following information and our office will be happy to provide you with the chiropractic benefits offered on your health care policy.  Make sure all blanks are completed.  We will respond promptly.

Thank You

Patient Name:

Insurance Company:

Insured's Name:

Policy #:

Plan #:

Plan Name:

Patient I.D. #
Date of Birth
Group #

Additional Info:

Patient Phone Number:

Insurance Co. # (800 number listed on back of insurance card)

For verification purposes, please type in the numbers and letters that you see below then press the Send Request button