Verify Your Health Insurance

Insurance Verification

Submit your health insurance information for verification. All information is held confidential.

Fill in all required fields (*) of the form below and we will notify you immediately when we have the verification completed.

If you have any questions regarding the completion of this online form or about using insurance to pay for treatment, please call 801-899-3480

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Patient Full Name*

Date of Birth*

Sex*

Patient Address 1*

Patient Address 2

City*

State*

Postal Code*

Patient Phone Number*

Policy Holder Number*

Policy Holder Date of Birth (DOB)*

Policy Holder Relationship*

Employer*

Employed

Student

Insurance Company*

Insurance Phone Number*

Insurance Member ID*

Insurance Group ID*

Type of Plan*

BIN #

RX BIN

RX Group

RX PCN

File Upload

Please upload a copy of your insurance card (front and back).

Drop files here or

Accepted file types: png, jpg, jpeg, gif, pdf, doc, docx, Max. file size: 20 MB, Max. files: 2.

Person submitting the form:

Your Email*

Your Name*

Your Contact Number*

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