Insurance Verification Form

Client Information

First name

Last name

Date of birth

Primary phone number

How would you like us to contact you?

Call

Home Address

Email address

Primary Insured

Relationship to Client

Primary's DOB

Primary Insurance / EAP Company Name

Insurance Phone Number

Member ID#

Group ID#

Secondary Insurance / EAP Company Name

Secondary Insurance Phone Number

Secondary Member ID#

Secondary Group ID#

Therapist Name

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