Thank you for your interest in Mind Body Co-op.

The following information is necessary for us to verify your insurance benefits. Please complete this confidential form and we will check your coverage before your first appointment with a provider.

If you are a current client at MBC and have new insurance for 2025, we will check your benefits after January 1, 2025 and will send you an updated benefits email.

Please direct any insurance verification questions to [email protected]. Thank you!

Are you a Current Patient at MBC? *

Full Name *

Date of birth *

Phone *

Email *

Address (Street, City, Zip)

This first section is about you. Please answer the following questions.

Preferred Name

Type of Service Requested *

Do you Have Insurance?

Where did you get your insurance

Choose an insurance plan. *

Insurance ID #

Insurance Group #

Insurance Upload-Front

Insurance Upload-Back

Name of Policy Holder *

Policy Holder Address *

Policy Holder Phone # *

Policy Holder email *

Do you give the billing department at Mind Body Co-op permission to contact the policy holder if we have any questions about your policy? No clinical information will ever be shared, only information related to billing your insurance carrier for you sessions. This is rare, but we need permission, just in case.

Yes

Maybe, please call me to discuss

Responsible Party

The Responsible Party for your account is the person who is responsible for balances on account. If the policy Holder and the Responsible Party are the same, we will use the contact information in the Policy Holder Section above.

Is the Responsible Party the same as the Policy Holder listed above? *

Yes

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

Please enter the name of the person who should receive your invoices.