Insurance Verification

First Name*

Last Name*

Date of Birth (mm/dd/yyyy)*

Email Address*

Phone #*

Home Address

Primary Insurance Plan (PLEASE ENTER ONLY ONE OF THE FOLLOWING: BCBS or UHC or NYSHIP or Aetna or Cigna)*

Member ID # (found on the front of the Insurance Card)*

Insurance Provider Phone # (usually found on the back of member id card)*

Specialist Co-Pay - Enter Specialist Co-Pay or NA if not available (found in front of the member ID card)*

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2510 Westchester Ave., Suite 110, Bronx, NY 10461