Insurance Benefits Report

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Benefits Verification

Client's Name(Required)

New Client or Existing Client?(Required)

New Client - Please Assign

Existing Client - Verifying Benefits Only

Insurance Provider(Required)

AetnaAetna CoventryAetna MedicaidAlliance CoalAllied NationalBlueCross Blue ShieldChampVACigna EAP ServicesCigna Health and Life Insurance Co.Edison Health SolutionsGPAGroup Benefit Services (GBS)Health SmartHealthcare HighwaysHealthCare Solutions GroupHealthChoiceHealthScopeHealthSmartHealthSmart Benefit SolutionsHumana MilitaryHumanaChoice PPOHumana MedicaidHumana MedicareMedicaMedicaidMedicare (original)Medicare (supplemental plan)Meritain HealthOklahoma Complete HealthOPTUM VAThe Kempton GroupTricare EastUMR - Wausau/UHISUnited Health Care/United Behavioral HealthUHC MedicareWebTPAOther

Client's Insurance ID(Required)

VA Authorization Number(Required)

Benefits(Required)

Additional Information

Anything the clinicians need to know but you don't want emailed to the client.

Client's Email Address(Required)

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