Private Health Insurance Benefit Request Form

 
 
 

Do you have health insurance? If so, depending on your company and policy, there is a possibility that massage is a covered benefit. We encourage you to contact a customer service representative with your insurance company. I provide complimentary insurance verification and appointments may only be booked after your information has been verified and confirmed. Please allow 2 business days for verification.

 
Client Name *
Client Name
Client Daytime Phone *
Client Daytime Phone
Client Birth Date *
Client Birth Date
Subscriber Date of Birth *
Subscriber Date of Birth
Insurance Company Phone Number *
Insurance Company Phone Number