Wellness At The Center

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Patient name

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Available times

Sun, Jan 24

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Mon, Jan 25

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Tue, Jan 26

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Wed, Jan 27

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Thu, Jan 28

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Fri, Jan 29

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Sat, Jan 30

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Insurance verification

Insurance Information

Insurance benefits must be verified by our clinic prior to your appointment or you will be charged the full price for the cost of your treatment. Any refunds due to you will be given after your insurance company has processed your claim, which may take up to six weeks. Use the online form to submit your insurance information, or you can call or fax us with your information. Dr. Small is in-network with: Aetna, Blue Cross Blue Shield (Regence / Anthem), Cigna / Great West. First Choice Health, Health Net, Kaiser Permanente / CHP, Lifewise of Oregon, Majoris, Multiplan, MODA, Pacific Source, Providence, Providence MCO (Worker’s Comp) and United Health Care. All providers are also able to bill for Motor Vehicle Accident Claims (personal injury) and may also bill as an out of network provider if allowed by your insurance. Thank you!

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

Employment Accident? Workers Compensation

Date of injury Please bring your authorization form to the office

Case/Claim #

Employers Name

Employers Address

Insurance company name

Insurance company phone

Insurance company address

I have read and accept the Terms of Use and Privacy Policy

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