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
Back of Card
Please Upload the Front Image of Your Insurance Card
Front of Card
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