Insurance Verification Form Name * First Name Last Name Date of Birth Email * Phone Phone Number Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Reason for Visit * Insurance Provider * Phone Insurance Provider Phone Number Member ID Number on Your Card * How Did You Hear About Us? * Facebook Friend Google Instagram Tik-Tok Other Are You the Policy Holder on the Account? * If not, please indicate the name, gender, and date of birth of the policy holder, and their relationship to you. Is There a Secondary Insurance * See our Privacy Policy at https://www.wellnessonpoint.com/privacy-policy for details on how we handle your information. We never share or sell your opt-in information. Yes, I agree to receive text messages from Wellness On Point at 516-395-7304. Message frequency varies and may include appointment reminder messages and data rates may apply. Opt out at any time by replying 'stop' or 'unsubscribe'. No, I do not want to receive messages from Wellness On Point Please allow 48 Hours for our Biller to confirm your insurance coverage.
