Insurance Eligibility Check

Insurance Eligibility Check
Name *
First Name Middle Name Last Name
DOB *
Month Day Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Primary Insurance Name *
Primary Insurance ID # *
Please include the phone number on the back of the card for commercial insurance:
Secondary Insurance Name
Secondary Insurance ID #
Please include the phone number on the back of the card for commercial insurance:
Upload Photos of Insurance cards front and back and or some for of identification card.

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Medical disclaimer

All information on this website is intended for instruction and informational purposes only. The authors are not responsible for any harm or injury that may result. Significant injury risk is possible if you do not follow due diligence and seek suitable professional advice about your injury. No guarantees of specific results are expressly made or implied on this website.

Can I get a cost estimate? If you do not have health insurance or plan to self-pay for our services, we will provide you with a Good Faith Estimate of our costs when you schedule at least 3 days in advance. If you would like to request a Good Faith Estimate before scheduling, please call our office at (972) 899-3473.

Insurance Eligibility Check

Insurance Eligibility Check

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