Insurance Verification

    CLIENT INFORMATION ( The person receiving treatment )

    PARENT GUARDIAN INFORMATION

    RESIDENTIAL ADDRESS | Used for internal communications and billing purposes only

    Payment Method

    INSURANCE DETAILS

    DRIVERS LICENSE UPLOAD

    Driving License Front
    Driving License Back

    INSURANCE CARD UPLOAD

    Insurance Card Front
    Insurance Card Back

    DIAGNOSIS / REPORT UPLOAD

    DIAGNOSIS / REPORT
    By clicking this box you are giving Thrive Therapy permission to use or disclose your protected health information (PHI) for treatment, payment and health care operations purposes.