Insurance Co. phone number (usually a 1-800 number):

Policy holder's First and Last Name:

ID listed on card (include alpha prefix, if present):

Policy holder's Date of Birth (mm/dd/yy):

Patient Name:

Relationship to policy holder (same or spouse):

Your Email Address:

Your Daytime Phone:

Type of Insurance: Group Health Workers Comp Auto Med Pay

Is this inquiry for: Chiropractic Massage Therapy Both

*As an alternative, you can photocopy your benefits card front and back and hand write your name, date of birth, and daytime phone number on your fax. We will get back to you within 24 hrs.