Insurance Verification

Patient Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Insurance Provider *

Member ID / Policy Number *

Found on your insurance card, usually on the front.

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.

Your information is encrypted and transmitted securely.