Benefits Verification Request

Patient Information

Who is this request for?

Please provide the core information needed to identify the patient.

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Best Phone Number *

Email Address

Your Relationship to Patient *

Preferred Contact Method

Phone Text Message Email

Insurance Details

Insurance Information

Enter the insurance information exactly as it appears on the card when possible.

Insurance Carrier *

Member ID *

Group Number

Policy Holder Name

Policy Holder Date of Birth

Relationship to Policy Holder

Service Type *

Date Needed By

What should we verify? *

Eligibility Status Copay Deductible Coinsurance Prior Authorization Requirement Referral Requirement Network Status Other Benefit Question

Select at least one item.

Additional Notes

Documents

Upload or Take a Picture

Upload a document, insurance card image, referral, or use your phone camera to take a picture.

Accepted file types: JPG, PNG, HEIC, WEBP, and PDF. Maximum size: 10 MB per file.

Insurance Card Front

Insurance Card Back

Referral, Order, or Supporting Document

Additional Documents

Document Notes

Submit Request

Review & Submit

Confirm that the information is ready to send to the admin team.

I confirm that I have reviewed the information and am ready to submit this benefits verification request.

This form sends the information to the designated admin email address. Do not display submitted personal or health information on the confirmation page.

Benefits Verification Request

Who is this request for?

Insurance Information

Upload or Take a Picture

Review & Submit

Clinic name

Local Arizona phone number

Hours of operation

Email (non-clinical questions)

Service area