Medical Insurance

We accept commercial plans: Aetna, Cigna, Florida Blue (Blue Cross Blue Shield), Oscar, UHC, Oxford, & UBH. Superbills available for out-of-network reimbursement.

Patient's Name

Exactly as it appear in the medical insurance card

First Name

Last Name

Patient's Email

Patient's Phone

(###)

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Patient's Address

Patient's Date of Birth

Insurance Provider Name

Member ID Number

Group Number

If no Group Number is listed on your insurance card, please leave this field blank.

Policy holder’s Name

Only answer "Policy Holder" questions if different from the patient (if the insurance is not under the client’s name.)

Policy holder’s Date of Birth

Policy Holder's Address

Policy Holder's Phone

(###)

###

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Policy Holder's Email

Medical Insurance

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