Insurance VERIFY YOUR COVERAGE To verify your insurance coverage, fill out the form below: Your Name (as it appears on card) Date of Birth Address Your Email Your Phone Insurance Provider Policy ID/Member # Group Number Are you the primary policy holder? Yes No If, no, please provide the name of Primary Policy Holder Date of Birth of Primary Policy Holder Please upload a photo of the front and back of your insurance card. Allowed file types png, gif, jpg, doc, pdf, jpeg Send