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:
Patient Address:

Name of Primary Insured:
Relationship to Primary Insured:
Employer:
Occupation:
Insured's Date of Birth:
 / 
 / 
Employed:
Student:
Insurance Company:
Insurance Phone:
-

Type of Plan:
Insurance ID Number:
Group Number:
Referral:
Enter Characters Below