Insurance Verification

Parkdale Center is happy to work with your private insurance provider to help you get the most benefit from your plan. Unfortunately, we do not accept federal nor state insurances such as Medicaid or HIP.

Patient Name*

Patient Email*

Patient Phone:

Area Code

Phone Number

Date of Birth:*

month

day

year

Sex:

Male

Female

Transgender

Other

Patient Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Name of Primary Insured:

First

Last

Relationship to Primary Insured:

Employer:

Occupation:

Insured's Date of Birth:

month

day

year

Employed:

Yes

Student:

Yes

Insurance Company:

Insurance Phone:

Area Code

Phone Number

Type of Plan:

Insurance ID Number:

Group Number:

Referral:

Enter Characters Below