Verify Insurance – TreatmentX

Insurance Verification

Today's Date

How did you hear about us?

Referred By

Referent's Phone

Client Information:

Client Name

Age

Drivers License #

State Issued

Marital Status

Address

Client Home Phone

Client Cell Phone

Client Email

Emergency Contact

Relationship

Emergency Contact Phone

Policy Holder Information:

Name

Address

Policy Holder SS#

Policy Holder DOB

Policy Holder Email

Policy Holder Phone

Insurance Information:

Primary Insurance Company

Primary Insurance Policy #

Primary Insurance Group #

Primary Insurance Phone

Other Insurance Company?

Other Insurance Policy #

Other Insurance Group #

Other Insurance Phone

Client History:

Known Issues