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

Date of Birth*

Sex Male
Female
Transgender
Other

Address

Address Line 2

City

State

Zip Code

Insurance Information

Name of Primary Insured

Relationship to Primary Insured

Employer

Insurance Company

Occupation

Insurance Company Phone #

Insured's Date of Birth

Employed Yes No

Student Yes No

Type of Plan

Group Number

Insurance ID Number

Referral