Victoria Brill

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Available times

Sat, Jul 31

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Sun, Aug 1

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Insurance verification

Insurance Information

I am a provider for the following insurance companies: Regence Aetna Premera Kaiser Cigna United Health Care First Choice Some medicare plans (please call your supplemental insurance and see if I am listed on your plan as a provider) ALWAYS CHECK WITH YOUR INSURANCE COMPANY TO SEE IF YOUR PLAN COVERS MASSAGE AND THAT I AM A PROVIDER

If you want to use insurance for your visit please fill out the fields below so that we can verify your coverage

Name of Primary Insurance (Blue Cross, Aetna, Anthem etc.)

Insurance Type (HMO, PPO etc.)

ID # on insurance card The ID number on your insurance card

Group number

Insurance Provider Phone Number Located on back of insurance card

Claim address Located on the back of insurance card

City

ZipCode

State

Covered under someone else's insurance plan? Select "yes" if you are covered under someone else's insurance

Patient relationship to insured

First Name of Insured Party First Name of the primary policy holder

Middle Name of Insured Party Middle Name of the primary policy holder

Last Name of Insured Party Last Name of the primary policy holder

Insured Party Date of Birth Date of birth of the primary policy holder

Auto Accident? No-Fault / Personal Injury

Date of accident Please bring your authorization form to the office

Case/Claim #

Case Manager's Name

Case Manager's Phone #

Address to submit claims

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