Name

First Name

Last Name

Date of Birth

DOB is needed to verify health insurance benefits

YYYY

Phone

(###)

###

####

Preferred Contact Method

Insurance Carrier

Primary Insured (if different from above)

First Name

Last Name

Primary Insured Date of Birth

YYYY

Member ID

Please write N/A if self-pay.

Group Number

Please write N/A if self-pay.

Customer Service or Provider Phone Number

This phone number can often be found on the back of your insurance card. Including this number will expedite verification of benefits. Please write N/A if unsure.

Zip Code

Please indicate the zip code that is attached to your health insurance plan.

Current Health in Tandem Therapist

Message

Please include any other relevant information that might help us verify your benefits.

Thank you! We will email or call you with your updated benefits information as soon as possible. Please be patient as getting ahold of insurance can sometimes be tricky, especially at the start of the year!

2025 Health Insurance Benefits Check

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