Personal Information

First Name:

Last Name:

E-mail:

Address:

City:

State:

Zip Code:

Phone:

Referred By:

Insurance Information

Insurance Name:

Insurance Telephone#:

Group Number:

Insured ID#:

Insured DOB: (MM/DD/YYYY)

Insurance Type: HMO PPO EPO POS Auto Insurance Worker's Comp

Comments:

Verification:

By submitting this form, I understand that my personal information will be used ONLY for the insurance verification process. It will be accessible to the staff at HighPoint Healing and Wellness and to a third-party biller. I understand that I have the right to request any and all restrictions to the use of disclosure of my health information.