Verify Insurance Coverage

For your information

Insurance benefits cannot be obtained for the requested services until a completed, signed copy of this form is received in our office. Verification will be provided within 72 hours after receipt and is good for 30 days. This information will be released to your insurance carrier for benefit verification. Please note that the information provided on a verification of benefits is not a guarantee of payment on our services. Prior verifications and authorizations only verify that the requested service meets the plan’s definition of medical necessity.