Verify Insurance CoverageNew Patient Intake Form 12 Name* First Last Email* Phone* Date of Birth* MM slash DD slash YYYY Insurance Company* Group #* Member ID #* Provider # (Providers Please Call)* Insurance Card (Front)*Max. file size: 300 MB.Please upload a picture of your insurance card Insurance Card (Back)*Max. file size: 300 MB.Please upload a picture of your insurance card I.D.*Max. file size: 300 MB.Please upload a valid picture ID