Insurance Eligibility Check
Complete the information below so our team can review your insurance benefits and determine whether your plan is eligible for coverage through our practice.
Please Read Before Completing This Form
At this time, we are NOT participating with:
- ❌ HMO Plans
- ❌ Marketplace / Exchange Plans (Affordable Care Act plans)
- ❌ Medicaid / MassHealth
- ❌ TRICARE
If your insurance falls into one of these categories, please do not complete this eligibility form, as we are unable to verify or bill these plans through this program.
To help us complete an accurate eligibility review, please:
- Complete every section of this form.
- Upload clear images of the front and back of your current insurance card.
- Enter the policyholder's information exactly as it appears on your insurance card.
- Tell us about any additional insurance coverage, even if you believe it is secondary.
- Use the insurance plan that will be active on the date of your appointment.
Providing complete and accurate information helps prevent delays in scheduling and reduces the likelihood of claim denials.
Important: An eligibility review is not a guarantee of insurance coverage or payment. Final coverage is determined by your insurance company after services are provided and your claim has been processed.
Once we have reviewed your benefits, our team will contact you within 24 hours with your coverage information and available scheduling options.