Insurance Verification

Insurance Verification Form

We highly recommend verifying your insurance benefits before your first appointment. Patients with unverified insurance coverage should be prepared to pay at the time of service. As a courtesy, we will assist you in verifying your insurance benefits. However, actual patient responsibility may vary from plan to plan. Your insurance carrier will provide detailed information according to your Explanation of Benefits (EOB) when you receive it. Please expect 24 up to 48 hours for us to verify your insurance. In case of urgent medical needs such as acute traumatic injury, acute onset of the chronic conditions, labor induction, IVF preparation etc, please call our office number at 425-392-8881 Tue-Fri to expedite the process.

Please enter "YES" if you accept the above term.

First name

Last name

Phone

Address

Insurance Plan

Insurance ID Number

Date of Birth

Primary Insurer's Insurance ID Number (if applicable)

Primary Insurer's Date of Birth (if applicable)