Complete only when requested by provider.
You can complete and submit the form directly to use without printing and emailing.
Cell Phone/Mobile Directions
Use the Verify Insurance page to fill out the form and submit your Insurance Verification sheet.
It will be sent directly to us.
Desktop Computer Directions
Fill out the form below to submit your Insurance Verification sheet. After the form has been filled out, use the 
button on the top right of the form toolbar. Choose the “with your changes” option to download the form. Then click the “Submit Form” button to upload your completed document.