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Insurance Verification

Please provide your information below so we can verify your insurance eligibility before your visit.

Mental Health for Everybody

Care That Meets You Where You Are

We understand that reaching out for help can feel overwhelming. That's why we've created a space where you can feel safe, supported, and empowered to take the next step.

Business Name

Proactive Medical and Wellness

Contact Email

proactivemedicalandwellness@gmail.com

Contact Phone

(346) 878-5272

Office Address

16821 Buccaneer Lane, Suite 200, Houston, TX 77058

Patient Information

First Name *

Last Name *

Email Address *

Phone Number *

Insurance Verification

Date of Birth *

Insurance Provider *

Member ID / Policy Number *

Found on your insurance card, usually on the front.

Patient Relationship *

I consent to insurance eligibility verification

By checking this box, I authorize Proactive Medical & Wellness Center to verify my insurance eligibility. My information will be handled in accordance with HIPAA regulations and our Privacy Policy.

If you have opted in above, you agree to receive SMS notifications regarding insurance verification updates. Message and data rates may apply. Reply STOP to opt out. Consent is not a condition of service.

Your information is encrypted and transmitted securely.

SMS Communication Consent

Users who submit this form may optionally consent to receive SMS notifications regarding insurance verification updates from Proactive Medical and Wellness. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out and HELP for assistance. Consent is not a condition of service.