Insurance Verification Form Name * First Name Last Name Email * Date of Birth * MM DD YYYY Phone * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Reason for Visit * Type of Session * Individual Session Family Session Insurance Provider * Member ID Number on Your Card * Insurance Provider Phone Number * (###) ### #### How Did You Hear About Us? * Facebook Friend Google Instagram Tik-Tok Other Are You the Policy Holder on the Account? * If not, please indicate the name, gender, and date of birth of the policy holder, and their relationship to you. Do you have a Secondary Insurance Plan? * If so, please provide the Insurance Carrier and Member ID number for that policy. See our Privacy Policy at https://www.theralisten.com/privacy-policy for details on how we handle your information. We never share or sell your opt-in information. Yes, I agree to receive text messages from TheraListen at 516-875-2075. Message frequency varies and may include appointment reminder messages and data rates may apply. Opt out at any time by replying 'stop' or 'unsubscribe'. No, I do not want to receive messages from TheraListen Please allow 48 Hours for our Biller to confirm your insurance coverage.
