Insurance Benefit Verification

Name *



Insurance Carrier *

If BCBS Federal Employee Program (FEP), which plan are you enrolled in?


Member Number*

Insurance Group / Enrollment Code*

Date of Birth*


Insurance company phone # for providers (usually on back of card)

How did you hear about our wellness center?*

Friend or family memberInsurance company websiteInternet searchFacebook/TwitterFlyerAnother healthcare practitioner or practiceOther

Any Additional Comments

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