Confirmation of Insurance Benefits Form

While we do not accept insurance assignment, as a courtesy we will submit a claim for you to your insurance carrier, letting them know that you’ve paid us so that they reimburse you directly for your services.

Below is a form that you can use to confirm your benefits from the insurance carrier. Here’s what to do:

1. Click on the link below to get a pdf of the form.
2. Print out the form
3. Call your insurance carrier
4. Ask them each of the questions on the form and fill out their reply
5. Before you hang up with them be sure to get a Call Reference Number from the Representative and write it at the bottom of the form.

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