Insurance Verification Form

Verification of Insurance
After completion of a free consultation with Evelyn, if you have health insurance, please enter your information below for a free verification of benefits to determine your out of pocket expense. This will ensure services rendered and payments are acceptable. ALL INFORMATION YOU SUBMIT IS CONFIDENTIAL. Please be advised that I accept limited insurances at this time although I am able to provide services to all insurance plans (with allowances) as an out of network provider.
Name*

First NameLast Name
Phone Number *

Area CodePhone Number
Date of Birth (person seeking treatment)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Name of Primary Member Insured (if Different from Above)*

First NameLast Name
Date of Birth of Primary Insured*
Primary's Phone Number

Area CodePhone Number
Primary Member's Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail*
Name of Insurance Carrier*
Type of Insurance Plan*
Insurance ID *
Please Upload the Back Image of Your Insurance Card

Upload a File
Back of Card Cancelof
Please Upload the Front Image of Your Insurance Card

Upload a File
Front of Card Cancelof
If your insurance is through your employer, please indicate the name of your employer
Employer Name
Comments or Inquiry
Should be Empty:

Verification of Insurance