Insurance Benefits Check Form

If you have a change in your health insurance coverage, please update my office with this new information before you come in for your next appointment. My office will gladly check your insurance coverage. However, you will be responsible directly to Wheels Darling Consulting for full payment of your account if your insurance company does not extend coverage for services rendered. To see a list of insurances my office processes, click here.

Name

First Name

Last Name

Date of Birth

YYYY

Email Address

Phone Number

Insurance Company

If other, please specify

Member ID #

Group ID #

Insurance Company Phone Number

Often on the back of the card