Verify My Insurance

Welcome to Healing Roots! If you are a new patient interested in having us bill insurance on your behalf, please fill the form below. Our fabulous biller can do a courtesy check of your benefits if she has at least two full business days to do this before your appointment.

All fields marked with an asterisk * are required. All of your information is encrypted and secure in accordance with the HIPPA Notice of Privacy Practices.

Alternatively, you can verify benefits yourself by downloading this form, printing it, calling your insurance company, filling it out and bringing it to us at your first appointment.

DISCLAIMER:  Healing Roots, PLLC doesn’t offer guarantee of insurance payment.

If you are human, leave this field blank.

Name

First Name *

Last Name *

Date of Birth

Month *

mm

Day *

dd

Year *

yyyy

Contact Info

Email Address *

Home Phone

Cell Phone *

Work Phone

Street Address *

Apt, Suite, Bldg

City *

State *

Zip Code *

Date of Your Initial Appointment (if known)

Month

mm

Day

dd

Year

yyyy

Policy Holder (if other than patient)

First Name

Last Name

Date of Birth

Month

mm

Day

dd

Year

yyyy

Insurance Info

Insurance Company *

Insurance Plan Name *

Group Number/ID *

Member Number/ID *

Insurance Company Phone

Verification *

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