Benefits Check Form

Please complete the following form to initiate an insurance benefit check.  Benefit checks will normally be completed within 2 business days.  The Healthcare Provider will be emailed the benefits.

Fields marked with an * are required

Please fill in all fields marked with * they are required.
When you have successfully submitted your form you will see this text:
'Thank you, your Benefit Check Request has been submitted. The provider of services will be contacted within 48 hours.'